Basic Information
| Provider Information | |||||||||
| NPI: | 1629276746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | PAUL | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 E LAUREL RD | ||||||||
| Address2: | UDP #1800 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
| FaxNumber: | 8565666419 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 E LAUREL RD | ||||||||
| Address2: | UDP #1800 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
| FaxNumber: | 8565666419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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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 | 2084P0800X | 25MB08671800 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 25MB08671800 | NJ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0290092 | 05 | NJ | MEDICAID |