Provider Demographics
NPI:1245316280
Name:WHITE, BRONSON B (DO)
Entity type:Individual
Prefix:DR
First Name:BRONSON
Middle Name:B
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 181
Mailing Address - Street 2:
Mailing Address - City:FORT HARRISON
Mailing Address - State:MT
Mailing Address - Zip Code:59636-0181
Mailing Address - Country:US
Mailing Address - Phone:406-447-7190
Mailing Address - Fax:
Practice Address - Street 1:3687 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636-9703
Practice Address - Country:US
Practice Address - Phone:406-447-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA 1121-99207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid
NM320057Medicare Oscar/Certification