Provider Demographics
NPI:1205573029
Name:WHITE, DARIUS BERNARD
Entity type:Individual
Prefix:
First Name:DARIUS
Middle Name:BERNARD
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 1:818 GAVIOTA AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-6308
Mailing Address - Country:US
Mailing Address - Phone:951-337-5042
Mailing Address - Fax:
Practice Address - Street 1:3850 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-1821
Practice Address - Country:US
Practice Address - Phone:323-751-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA175T00000X
CAMPSS-YUFPIH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker