Basic Information
| Provider Information | |||||||||
| NPI: | 1558504357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | JASON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 N STAPLEY DR | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852033002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808347546 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1855 N STAPLEY DR | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808347546 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2009 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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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 | 207Q00000X | 46427 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 46427 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A136139 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 720724 | 05 | AZ | MEDICAID |