Healthcare Provider Details

I. General information

NPI: 1225077449
Provider Name (Legal Business Name): JAMES GRADY WHITE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 09/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1688 W GRANADA BLVD SUITE 2B
ORMOND BEACH FL
32174
US

IV. Provider business mailing address

1688 W GRANADA BLVD SUITE 2B
ORMOND BEACH FL
32174
US

V. Phone/Fax

Practice location:
  • Phone: 386-677-3530
  • Fax: 386-673-1933
Mailing address:
  • Phone: 386-677-3530
  • Fax: 386-673-1933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0011383
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: