Provider Demographics
NPI: | 1629276746 |
---|---|
Name: | WHITE, CHRISTIAN PAUL (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | CHRISTIAN |
Middle Name: | PAUL |
Last Name: | WHITE |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 42 E LAUREL RD STE 1800-A |
Mailing Address - Street 2: | |
Mailing Address - City: | STRATFORD |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 08084-1354 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 856-566-6843 |
Mailing Address - Fax: | 856-566-6419 |
Practice Address - Street 1: | 42 E LAUREL RD STE 1800-A |
Practice Address - Street 2: | |
Practice Address - City: | STRATFORD |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08084-1354 |
Practice Address - Country: | US |
Practice Address - Phone: | 856-566-6843 |
Practice Address - Fax: | 856-566-6419 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-07-10 |
Last Update Date: | 2024-03-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | 25MB08671800 | 2084P0805X, 2084P0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No | 2084P0805X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NJ | 0290092 | Medicaid | |
NJ | 0290092 | Medicaid |