Provider Demographics
NPI:1841410651
Name:WHITE, WALTER IRVIN
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:IRVIN
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 1:11240 HESS COURT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-4961
Mailing Address - Country:US
Mailing Address - Phone:240-346-6915
Mailing Address - Fax:301-843-3803
Practice Address - Street 1:11240 HESS CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-4961
Practice Address - Country:US
Practice Address - Phone:240-346-6915
Practice Address - Fax:301-843-3803
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver