Healthcare Provider Details

I. General information

NPI: 1922058767
Provider Name (Legal Business Name): GARY ALFRED WHITE OD OPTOMETRIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 BROWNING RD
COLUMBIA SC
29210-6924
US

IV. Provider business mailing address

1620 BROWNING RD
COLUMBIA SC
29210-6924
US

V. Phone/Fax

Practice location:
  • Phone: 803-732-4099
  • Fax: 803-227-8992
Mailing address:
  • Phone: 803-732-4099
  • Fax: 803-227-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number595
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number595
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: