Healthcare Provider Details

I. General information

NPI: 1568683506
Provider Name (Legal Business Name): DOUGLAS RAY WHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MOUNTAIN MEADOW LN
ROCK SPRING GA
30739-2651
US

IV. Provider business mailing address

PO BOX 729
RINGGOLD GA
30736-0729
US

V. Phone/Fax

Practice location:
  • Phone: 770-815-0668
  • Fax:
Mailing address:
  • Phone: 706-935-6442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number029557
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29557
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License Number029557
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: