Provider Demographics
NPI:1770536856
Name:WHITE, RICHARD A (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:WHITE
Suffix:
Gender:M
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 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-681-3767
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:515 E PROMENADE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2966
Practice Address - Country:US
Practice Address - Phone:573-582-0157
Practice Address - Fax:573-581-4995
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005000797207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00239066OtherRR MEDICARE
MO207249301Medicaid
I27706Medicare UPIN
MO207249301Medicaid
MOP00239066OtherRR MEDICARE
MO928485236Medicare PIN