Provider Demographics
NPI:1336252477
Name:WHITE, JOHNNY LEE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:LEE
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11700 PRESTON RD SUITE 660
Mailing Address - Street 2:PMB-136
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:877-750-1027
Mailing Address - Fax:877-750-1079
Practice Address - Street 1:2550 N ESPLANADE ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-4736
Practice Address - Country:US
Practice Address - Phone:877-750-1027
Practice Address - Fax:877-750-1079
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1581174400000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC23392Medicare UPIN
TX00T12UMedicare ID - Type Unspecified