Provider Demographics
NPI:1689601379
Name:WHITE, JOHN MAXWELL JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MAXWELL
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:MAXWELL
Other - Last Name:WHITE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35C.001118208800000X
GA028233208800000X
WAMD61499859208800000X
TN69973208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000328237EMedicaid
GA208282OtherBLUE CROSS BLUE SHIELD
P00019582OtherRAILROAD MEDICARE
34BDDJVMedicare ID - Type Unspecified
GA000328237EMedicaid