Provider Demographics
NPI:1457336935
Name:WHITE, KELVIN D (MD)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:D
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 DEVANT ST
Mailing Address - Street 2:SUITE 902
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2710
Mailing Address - Country:US
Mailing Address - Phone:770-716-8228
Mailing Address - Fax:770-716-6588
Practice Address - Street 1:101 DEVANT ST
Practice Address - Street 2:SUITE 902
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2710
Practice Address - Country:US
Practice Address - Phone:770-716-8228
Practice Address - Fax:770-716-6588
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2012-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA33753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000445156FMedicaid
GA000445156FMedicaid
E12476Medicare UPIN