Basic Information
| Provider Information | |||||||||
| NPI: | 1407959422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6149 | ||||||||
| Address2: | |||||||||
| City: | ALOHA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970070149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033528657 | ||||||||
| FaxNumber: | 5033528658 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 MONMOUTH ST | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038381133 | ||||||||
| FaxNumber: | 5038385138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD10976 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 26934-0 | 05 | OR | MEDICAID |