Healthcare Provider Details

I. General information

NPI: 1336217496
Provider Name (Legal Business Name): LOUIS ELDEAN WHITE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 HORTON RD SUITE 10
JACKSON MI
49203-5594
US

IV. Provider business mailing address

1931 HORTON RD SUITE 10
JACKSON MI
49203-5594
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-8251
  • Fax: 517-788-8704
Mailing address:
  • Phone: 517-788-8251
  • Fax: 517-788-8704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901000896
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number5901000896
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: