Provider Demographics
NPI:1649202284
Name:WHITE, LAURIE B (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:B
Last Name:WHITE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-6422
Mailing Address - Country:US
Mailing Address - Phone:620-227-8622
Mailing Address - Fax:620-227-7099
Practice Address - Street 1:2010 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-6422
Practice Address - Country:US
Practice Address - Phone:620-227-8622
Practice Address - Fax:620-227-7099
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1213-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100218630BMedicaid
KST43765Medicare UPIN
KS5339Medicare ID - Type Unspecified