Healthcare Provider Details

I. General information

NPI: 1265920516
Provider Name (Legal Business Name): MARY WHITE STORM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S CREASY LN
LAFAYETTE IN
47905-4972
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-502-4400
  • Fax: 765-502-4401
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2026-03021
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD61401511
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number15263-320
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD194613
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number111364
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number75892
License Number StateTN
# 7
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01100126A
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number351860
License Number StateLA
# 9
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number75892
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: