Provider Demographics
NPI:1659515211
Name:WHITE, BETHANIE ROSELLA (MD)
Entity type:Individual
Prefix:
First Name:BETHANIE
Middle Name:ROSELLA
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3723 W 12600 S STE 270
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7296
Practice Address - Country:US
Practice Address - Phone:801-285-4600
Practice Address - Fax:801-285-4601
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60449457208600000X
UT7771498-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery