Provider Demographics
NPI:1992748180
Name:WHITE, MARK DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
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 1:5495 MAPLE LANE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-9589
Mailing Address - Country:US
Mailing Address - Phone:304-574-1888
Mailing Address - Fax:304-574-1891
Practice Address - Street 1:650 PETER JEFFERSON PKWY STE 290
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8848
Practice Address - Country:US
Practice Address - Phone:434-297-7140
Practice Address - Fax:434-297-7235
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14161207Q00000X
VA0101264388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0057307000Medicaid
WV9300961Medicare ID - Type Unspecified
WV0057307000Medicaid