Provider Demographics
NPI:1689665614
Name:WHITE, CHARLES WESLEY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:180 OLD HICKORY BLVD STE L
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2500
Mailing Address - Country:US
Mailing Address - Phone:731-661-2750
Mailing Address - Fax:731-664-6817
Practice Address - Street 1:180 OLD HICKORY BLVD STE L
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2500
Practice Address - Country:US
Practice Address - Phone:731-661-2750
Practice Address - Fax:731-664-6817
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN21679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN626001636OtherHEALTH PARTNERS
TN626001636OtherUNITED HEALTHCARE
TN3061622Medicaid
TN3061623Medicaid
TN4057255OtherBLUE CROSS BLUE SHIELD
TN27438OtherTLC
TN152667OtherUNISON
TNJT1042OtherCIGNA
TN626001636OtherUSA MANAGED CARE
TNP00034970OtherRAILROAD MEDICARE
TN27438OtherTLC
TNJT1042OtherCIGNA
TN3061625Medicare ID - Type Unspecified
TN4057255OtherBLUE CROSS BLUE SHIELD