Provider Demographics
NPI:1013110774
Name:WHITE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 BELTON ST
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1401
Mailing Address - Country:US
Mailing Address - Phone:301-466-6283
Mailing Address - Fax:
Practice Address - Street 1:1525 POINTER RIDGE PL
Practice Address - Street 2:#304
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1833
Practice Address - Country:US
Practice Address - Phone:301-466-6283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist