Provider Demographics
NPI:1881024933
Name:GORDON ELLIS WHITE II MD LLC
Entity Type:Organization
Organization Name:GORDON ELLIS WHITE II MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-801-4070
Mailing Address - Street 1:301 W BOUNDARY AVE
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-3427
Mailing Address - Country:US
Mailing Address - Phone:318-648-3034
Mailing Address - Fax:318-648-3104
Practice Address - Street 1:301 W BOUNDARY AVE
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3427
Practice Address - Country:US
Practice Address - Phone:318-648-3034
Practice Address - Fax:318-648-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.025398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty