Provider Demographics
NPI:1629288584
Name:WHITE, GERALD THOMAS (RPT)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:THOMAS
Last Name:WHITE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 E 437
Mailing Address - Street 2:
Mailing Address - City:SPAVINAW
Mailing Address - State:OK
Mailing Address - Zip Code:74366-1223
Mailing Address - Country:US
Mailing Address - Phone:918-589-2226
Mailing Address - Fax:918-589-2239
Practice Address - Street 1:569 E 437
Practice Address - Street 2:
Practice Address - City:SPAVINAW
Practice Address - State:OK
Practice Address - Zip Code:74366-1223
Practice Address - Country:US
Practice Address - Phone:918-589-2226
Practice Address - Fax:918-589-2239
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist