Basic Information
| Provider Information | |||||||||
| NPI: | 1457461774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073589216 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073589216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 7283A | WY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 313803 | 01 | WY | BCBS OF WYOMING | OTHER |