Basic Information
| Provider Information | |||||||||
| NPI: | 1477559631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043964893 | ||||||||
| Practice Location | |||||||||
| Address1: | 11945 SAN JOSE BLVD. | ||||||||
| Address2: | BLDG 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | ME0075474 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 107281 | 01 | FL | FHCP | OTHER | P01102622 | 01 | FL | RAILROAD MEDICARE | OTHER |