Provider Demographics
NPI:1639347016
Name:TW WHITE OD PC
Entity Type:Organization
Organization Name:TW WHITE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:WM
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD,PC
Authorized Official - Phone:417-466-2100
Mailing Address - Street 1:410 W HAYWARD DR
Mailing Address - Street 2:PO BOX 311
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-7368
Mailing Address - Country:US
Mailing Address - Phone:417-466-2100
Mailing Address - Fax:417-466-0432
Practice Address - Street 1:410 W HAYWARD DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-7368
Practice Address - Country:US
Practice Address - Phone:417-466-2100
Practice Address - Fax:417-466-0432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002104332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0676890001Medicare NSC