Provider Demographics
NPI:1649293952
Name:WHITE, MARY C (DPM)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:WHITE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6451 E RIVERSIDE BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6451 E RIVERSIDE BLVD
Practice Address - Street 2:STE 104
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4421
Practice Address - Country:US
Practice Address - Phone:815-282-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004011213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4760030001OtherDMERC
ILP00050197OtherRAILROAD MEDICARE
IL60101278OtherBC/BS
ILT38576Medicare UPIN
ILP00050197OtherRAILROAD MEDICARE
IL207544Medicare PIN