Basic Information
Provider Information | |||||||||
NPI: | 1447474234 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WHITE-WILSON MEDICAL CENTER, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WHITE-WILSON BWB PEDS DEPARTMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1005 MAR WALT DRIVE | ||||||||
Address2: | BUSINESS OFFICE | ||||||||
City: | FORT WALTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 325476707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508638105 | ||||||||
FaxNumber: | 8508638548 | ||||||||
Practice Location | |||||||||
Address1: | 2001 E. HIGHWAY 20 | ||||||||
Address2: | PEDIATRIC DEPARTMENT | ||||||||
City: | NICEVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 32578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508974400 | ||||||||
FaxNumber: | 8508970623 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RIGBY | ||||||||
AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
AuthorizedOfficialMiddleName: | WINSTON | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8508638150 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.