Provider Demographics
NPI:1003815358
Name:WHITE, MICHAEL JAY (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAY
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:PO BOX 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:803-796-4251
Mailing Address - Fax:803-796-4449
Practice Address - Street 1:1830 PONDFIELD RD
Practice Address - Street 2:SUITE A
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-9522
Practice Address - Country:US
Practice Address - Phone:803-405-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73670163WW0000X
FLME108837207Q00000X
SC23345207Q00000X
GA0736702083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT74354Medicaid
FL003523200Medicaid
SCH58521Medicare UPIN
FL003523200Medicaid
FLFD856ZMedicare UPIN