Provider Demographics
NPI:1689172611
Name:WHITE, DERRON (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:DERRON
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 BARATARIA BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2324 BARATARIA BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-251-8549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management