Provider Demographics
NPI:1639169485
Name:WHITE, GORDON ELLIS II (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:ELLIS
Last Name:WHITE
Suffix:II
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 1:1900 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5100
Mailing Address - Country:US
Mailing Address - Phone:318-801-4070
Mailing Address - Fax:318-554-4807
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:318-801-4070
Practice Address - Fax:318-554-4807
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025398207Q00000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1423688Medicaid
LA1423688Medicaid
LAH97228Medicare UPIN