Provider Demographics
NPI:1760861397
Name:WHITE, JASON W (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:W
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10122 E 10TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229
Practice Address - Country:US
Practice Address - Phone:317-355-5717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01079068A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300017136Medicaid