Provider Demographics
NPI:1639569742
Name:WHITE, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 N HIGH ST
Mailing Address - Street 2:SUITE NUMBER 5
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8365
Mailing Address - Country:US
Mailing Address - Phone:573-204-7620
Mailing Address - Fax:573-204-0222
Practice Address - Street 1:2370 N HIGH ST
Practice Address - Street 2:SUITE NUMBER 5
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-8365
Practice Address - Country:US
Practice Address - Phone:573-204-7620
Practice Address - Fax:573-204-0222
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker