Provider Demographics
NPI:1598745390
Name:WHITE, GREGORY R (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
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 1:6926 BRIER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-4211
Mailing Address - Country:US
Mailing Address - Phone:863-698-8643
Mailing Address - Fax:863-534-0486
Practice Address - Street 1:6926 BRIER CREEK CT
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-4211
Practice Address - Country:US
Practice Address - Phone:863-698-8643
Practice Address - Fax:863-534-0486
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0039946207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067071500Medicaid
FL53636OtherBCBS
FL067071500Medicaid
FL53636FMedicare ID - Type UnspecifiedMEDICARE