Provider Demographics
NPI:1558480160
Name:WHITE, JOSEPH EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EDWARD
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1607
Mailing Address - Country:US
Mailing Address - Phone:847-455-3335
Mailing Address - Fax:
Practice Address - Street 1:547 EDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1607
Practice Address - Country:US
Practice Address - Phone:847-455-3335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3652104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052104Medicaid
657720Medicare ID - Type Unspecified