Basic Information
Provider Information | |||||||||
NPI: | 1689601379 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | MAXWELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHITE | ||||||||
OtherFirstName: | J | ||||||||
OtherMiddleName: | MAXWELL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 275 COLLIER RD NW | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303091709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4046054848 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 275 COLLIER RD NW | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303091709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4046054848 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2006 | ||||||||
LastUpdateDate: | 03/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 028233 | GA | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 208282 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | P00019582 | 01 |   | RAILROAD MEDICARE | OTHER | 000328237E | 05 | GA |   | MEDICAID |