Basic Information
Provider Information | |||||||||
NPI: | 1487650123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | JOE | ||||||||
MiddleName: | MIKE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHITE | ||||||||
OtherFirstName: | J | ||||||||
OtherMiddleName: | MIKE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 220 N RIDGEWAY DR | ||||||||
Address2: |   | ||||||||
City: | CLEBURNE | ||||||||
State: | TX | ||||||||
PostalCode: | 760334115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175564800 | ||||||||
FaxNumber: | 8175564825 | ||||||||
Practice Location | |||||||||
Address1: | 3517 SW WILSHIRE BLVD | ||||||||
Address2: |   | ||||||||
City: | JOSHUA | ||||||||
State: | TX | ||||||||
PostalCode: | 760589659 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174471151 | ||||||||
FaxNumber: | 8175298927 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2005 | ||||||||
LastUpdateDate: | 01/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F6345 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 121078303 | 05 | TX |   | MEDICAID |