Healthcare Provider Details

I. General information

NPI: 1124001458
Provider Name (Legal Business Name): WAYNE BARLOW WHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 E STATE ROAD 44 STE 5
CONNERSVILLE IN
47331-8292
US

IV. Provider business mailing address

1770 W COUNTY ROAD 50 N
CONNERSVILLE IN
47331-8443
US

V. Phone/Fax

Practice location:
  • Phone: 765-825-0511
  • Fax: 765-827-1247
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01032858
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: