Provider Demographics
NPI:1942285895
Name:WHITE, GARY C (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:C
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 1:2019 S HENDERSON BLVD
Mailing Address - Street 2:#4
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3672
Mailing Address - Country:US
Mailing Address - Phone:903-988-0605
Mailing Address - Fax:903-988-9804
Practice Address - Street 1:2019 S HENDERSON BLVD
Practice Address - Street 2:#4
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3672
Practice Address - Country:US
Practice Address - Phone:903-988-0605
Practice Address - Fax:903-988-9804
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096910702Medicaid
TX096910702Medicaid
TX00788GMedicare ID - Type Unspecified