Provider Demographics
NPI:1336146653
Name:WHITE, BONNIE K (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:K
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 SAINT ANDREWS CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2063
Mailing Address - Country:US
Mailing Address - Phone:904-273-8039
Mailing Address - Fax:
Practice Address - Street 1:1100 SAWGRASS VILLAGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5048
Practice Address - Country:US
Practice Address - Phone:904-285-9355
Practice Address - Fax:904-285-7442
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99063208000000X
OH35062590208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1892968001OtherCIGNA
OHOC07700OtherNATIONWIDE HEALTH PLANS
OH0859110Medicaid
OH341106740029OtherCARESOURCE
OH83307OtherPHCS
OH1006360OtherUNITED HEALTHCARE
OHR62590OtherSUMMA CARE
OH000000127390OtherANTHEM
OH4211817OtherAETNA
OH53013OtherQUAL CHOICE