Provider Demographics
NPI:1184606527
Name:WHITE, JOHN JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
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 1:1750 E LAKE SHORE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3809
Mailing Address - Country:US
Mailing Address - Phone:217-428-6300
Mailing Address - Fax:217-428-6322
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:STE 200
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3809
Practice Address - Country:US
Practice Address - Phone:217-428-6300
Practice Address - Fax:217-428-6322
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI8411OtherMEDICARE TRAVELERS
E46065Medicare UPIN
L66816Medicare ID - Type Unspecified