Healthcare Provider Details

I. General information

NPI: 1386931202
Provider Name (Legal Business Name): MATTHEW CHRISTIAN WHITE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 09/11/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 MDG 5955 ZEAMER AVE
JBER AK
99506
US

IV. Provider business mailing address

673 MDG 5955 ZEAMER AVE
JBER AK
99506
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-1815
  • Fax:
Mailing address:
  • Phone: 907-580-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number205569
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1679854491
Identifier TypeMEDICAID
Identifier StateID
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: