Provider Demographics
NPI:1952632416
Name:WHITE, GARY CLARK JR (CFA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:CLARK
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HIDDEN LN
Mailing Address - Street 2:
Mailing Address - City:JOURDANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78026-4706
Mailing Address - Country:US
Mailing Address - Phone:830-480-9021
Mailing Address - Fax:
Practice Address - Street 1:120 HIDDEN LN
Practice Address - Street 2:
Practice Address - City:JOURDANTON
Practice Address - State:TX
Practice Address - Zip Code:78026-4706
Practice Address - Country:US
Practice Address - Phone:830-480-9021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-23
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118451246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant