Provider Demographics
NPI:1457388597
Name:WHITE, JOHN MIKE (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MIKE
Last Name:WHITE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4088 E. IH 20 SERVICE RD.
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087
Mailing Address - Country:US
Mailing Address - Phone:817-596-0646
Mailing Address - Fax:817-594-9190
Practice Address - Street 1:4088 E INTERSTATE 20 SERVICE RD S
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087-3647
Practice Address - Country:US
Practice Address - Phone:817-594-9191
Practice Address - Fax:817-594-9190
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2770TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0098FCOtherBCBS GROUP
TX7462322OtherAETNA
TX80896QOtherBCBS
TXP0064159OtherPALMETTO RAILROAD
TXDA5868OtherPALMETTO GRP
TX7462322OtherAETNA
TXP0064159OtherPALMETTO RAILROAD
TX4974600001Medicare NSC