Basic Information
| Provider Information | |||||||||
| NPI: | 1518005917 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE-WILSON MEDICAL CENTER, P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WHITE-WILSON PEDS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 MAR WALT DR | ||||||||
| Address2: | PEDIATRIC DEPARTMENT | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508638203 | ||||||||
| FaxNumber: | 8508620977 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 MAR WALT DR | ||||||||
| Address2: | PEDIATRIC DEPARTMENT | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508638203 | ||||||||
| FaxNumber: | 8508620977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RIGBY | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8508638131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.