Healthcare Provider Details

I. General information

NPI: 1225034317
Provider Name (Legal Business Name): CHARLES C WHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CHURCH AVE STE 201
WAREHAM MA
02571-2093
US

IV. Provider business mailing address

40 CHURCH AVE STE 201
WAREHAM MA
02571-2093
US

V. Phone/Fax

Practice location:
  • Phone: 508-295-3193
  • Fax: 508-295-4635
Mailing address:
  • Phone: 508-295-3193
  • Fax: 508-295-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number53631
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: