Provider Demographics
NPI:1831805852
Name:WHITE, BENJAMIN GRADY
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:GRADY
Last Name:WHITE
Suffix:
Gender:M
Credentials:
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 154
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0154
Mailing Address - Country:US
Mailing Address - Phone:918-917-3350
Mailing Address - Fax:
Practice Address - Street 1:312 CHAPMAN STREET
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571
Practice Address - Country:US
Practice Address - Phone:918-917-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health