Healthcare Provider Details

I. General information

NPI: 1558052621
Provider Name (Legal Business Name): EBONY DIONNE WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6909 N LOOP 1604 E
SAN ANTONIO TX
78247-5317
US

IV. Provider business mailing address

6909 N LOOP 1604 E
SAN ANTONIO TX
78247-5317
US

V. Phone/Fax

Practice location:
  • Phone: 210-750-2662
  • Fax:
Mailing address:
  • Phone: 210-750-2662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number83114107
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: