Provider Demographics
NPI:1629016787
Name:WHITE, HARRY C (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:C
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 1:4105 BRIARGATE BLVD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3490
Mailing Address - Country:US
Mailing Address - Phone:719-282-2511
Mailing Address - Fax:719-282-2545
Practice Address - Street 1:4105 BRIARGATE BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3490
Practice Address - Country:US
Practice Address - Phone:719-282-2511
Practice Address - Fax:719-282-2545
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31218208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20439OtherKAISER COMMERCIAL
CO25584251Medicaid
CO25584251Medicaid