Basic Information
| Provider Information | |||||||||
| NPI: | 1013197565 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARK W WHITE MD,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1890 LPGA BLVD | ||||||||
| Address2: | STE 250 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321177131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862740250 | ||||||||
| FaxNumber: | 3862740269 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 LPGA BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321177130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862740250 | ||||||||
| FaxNumber: | 3862740269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3862740250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME75474 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.