Provider Demographics
NPI:1104923093
Name:WHITE, BRYAN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:KEITH
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5613 HERON DR E
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2503
Mailing Address - Country:US
Mailing Address - Phone:541-799-4441
Mailing Address - Fax:972-502-9191
Practice Address - Street 1:1200 S HALL ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-6318
Practice Address - Country:US
Practice Address - Phone:541-799-4769
Practice Address - Fax:972-502-9191
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ4607207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125214003Medicaid
TX82V273OtherBCBS
TX82V273Medicare PIN
TX82V273OtherBCBS