Provider Demographics
NPI:1922058767
Name:WHITE, GARY ALFRED (OD OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALFRED
Last Name:WHITE
Suffix:
Gender:M
Credentials:OD OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 BROWNING RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-6924
Mailing Address - Country:US
Mailing Address - Phone:803-732-4099
Mailing Address - Fax:803-227-8992
Practice Address - Street 1:1620 BROWNING RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-6924
Practice Address - Country:US
Practice Address - Phone:803-732-4099
Practice Address - Fax:803-227-8992
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT595152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F2728Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
TX00W375Medicare ID - Type UnspecifiedGROUP NUMBER