Provider Demographics
NPI:1245345057
Name:WHITE, RONALD LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:LYNN
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 1:1611 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2719
Mailing Address - Country:US
Mailing Address - Phone:479-890-5881
Mailing Address - Fax:479-890-5092
Practice Address - Street 1:1611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2719
Practice Address - Country:US
Practice Address - Phone:479-890-5881
Practice Address - Fax:479-890-5092
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6004174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F920OtherPTAN
AR112265001Medicaid
AR5F920OtherPTAN