Healthcare Provider Details

I. General information

NPI: 1487677944
Provider Name (Legal Business Name): RONALD LEMOND WHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 S AUTO MALL RD
BLOOMINGTON IN
47401-5430
US

IV. Provider business mailing address

60MDG / PAIN CLINIC 101 BODIN CIRCLE
TRAVIS AFB CA
94535-1800
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-2700
  • Fax:
Mailing address:
  • Phone: 707-423-3216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number01071396A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD425768
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number134516
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number0101240242
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberL4803
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number29027
License Number StateMS
# 7
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01071396A
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberL4803
License Number StateTX
# 9
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number134516
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number134516
License Number StateCA
# 11
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberL4803
License Number StateTX
# 12
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number39369
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: