Healthcare Provider Details

I. General information

NPI: 1427317262
Provider Name (Legal Business Name): DESMOND THOMAS WHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 E CASS ST
JOLIET IL
60432-2812
US

IV. Provider business mailing address

620 UNITY CT
SHOREWOOD IL
60404-9595
US

V. Phone/Fax

Practice location:
  • Phone: 815-726-3377
  • Fax:
Mailing address:
  • Phone: 181-558-2432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.054369
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: