Provider Demographics
NPI:1134213523
Name:WHITE, LARRY D (DO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:WHITE
Suffix:
Gender:M
Credentials:DO
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG NORTHSIDE
Practice Address - Street 2:5901 HARPER DR NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-823-8888
Practice Address - Fax:505-823-8275
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1129992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM71091Medicaid
NM71091Medicaid
E26934Medicare UPIN