Provider Demographics
NPI:1962491902
Name:WHITE, MARK S (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:WHITE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 N US 27
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-1129
Mailing Address - Country:US
Mailing Address - Phone:989-224-3937
Mailing Address - Fax:989-224-4999
Practice Address - Street 1:1002 N US 27
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1129
Practice Address - Country:US
Practice Address - Phone:989-224-3937
Practice Address - Fax:989-224-4999
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4294310Medicaid
MI4294310Medicaid
T33608Medicare UPIN