Basic Information
| Provider Information | |||||||||
| NPI: | 1093762577 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITE OAK FAMILY PHYSICIANS, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 550 WHITE OAK ST | ||||||||
| Address2: | |||||||||
| City: | ASHEBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272034710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366251360 | ||||||||
| FaxNumber: | 3366251889 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 WHITE OAK ST | ||||||||
| Address2: | |||||||||
| City: | ASHEBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272034710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366251360 | ||||||||
| FaxNumber: | 3366251889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3366251360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1735 | 01 | NC | BCBS GROUP NUMBER | OTHER | 7901735 | 05 | NC | MEDICAID |