Healthcare Provider Details

I. General information

NPI: 1760166656
Provider Name (Legal Business Name): SAMUEL MILTON WHITE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5075 RUFFIN RD STE B
SAN DIEGO CA
92123-1698
US

IV. Provider business mailing address

5075 RUFFIN RD STE B
SAN DIEGO CA
92123-1698
US

V. Phone/Fax

Practice location:
  • Phone: 858-278-4720
  • Fax: 858-278-3640
Mailing address:
  • Phone: 858-278-4720
  • Fax: 858-278-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: