Provider Demographics
NPI:1760527980
Name:WHITE, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
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 1:623 VALMONT PL
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4405
Mailing Address - Country:US
Mailing Address - Phone:516-887-9155
Mailing Address - Fax:
Practice Address - Street 1:11 CEDAR LN
Practice Address - Street 2:
Practice Address - City:SANDS POINT
Practice Address - State:NY
Practice Address - Zip Code:11050-1334
Practice Address - Country:US
Practice Address - Phone:516-887-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1951641164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01126425Medicaid