Provider Demographics
NPI:1881793644
Name:WHITE, MARK PHILIP (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILIP
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 1:3309 E MULBERRY CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-2425
Mailing Address - Country:US
Mailing Address - Phone:812-331-2709
Mailing Address - Fax:
Practice Address - Street 1:RR #1 BOX 1000
Practice Address - Street 2:GREENE COUNTY GENERAL
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-9457
Practice Address - Country:US
Practice Address - Phone:812-847-2281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038810A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000594833OtherBLUE SHIELD
IN100468280 DMedicaid
IN000000594833OtherBLUE SHIELD