Basic Information
| Provider Information | |||||||||
| NPI: | 1063436160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE-GREEN | ||||||||
| FirstName: | LATAMIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | LATAMIA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14527 7TH ST | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335233102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525211474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14527 7TH ST | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335233102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525211474 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | ME-93569 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1549814 | 01 | AL | UBH-PLUS | OTHER | 51528383 | 01 | AL | BCBS | OTHER | 000007535 | 01 | AL | BLUE CROSS | OTHER | 1549813 | 01 | AL | UBH-BASIC | OTHER | 051523806 | 01 | AL | BLUE CROSS | OTHER | 051530813 | 01 | AL | BC FEDERAL EHBP | OTHER | 051523807 | 01 | AL | BLUE CROSS | OTHER | 003907200 | 05 | FL | MEDICAID | 051523805 | 01 | AL | BLUE CROSS | OTHER |