Healthcare Provider Details

I. General information

NPI: 1245655968
Provider Name (Legal Business Name): JERRY RAY WHITE II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 23RD ST STE 230
ASHLAND KY
41101-2868
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-324-4745
  • Fax: 606-324-4941
Mailing address:
  • Phone: 606-408-9571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberTP372
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: