Healthcare Provider Details

I. General information

NPI: 1568440576
Provider Name (Legal Business Name): MATTHEW WILLIAM WHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MAPLE ST
WACONIA MN
55387-1791
US

IV. Provider business mailing address

500 S MAPLE ST
WACONIA MN
55387-1752
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-2191
  • Fax:
Mailing address:
  • Phone: 952-442-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number44138
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number44138
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44138
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: