Healthcare Provider Details

I. General information

NPI: 1497370563
Provider Name (Legal Business Name): DONOVAN R WHITE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

2985 DISTRICT AVE APT 394
FAIRFAX VA
22031-1550
US

V. Phone/Fax

Practice location:
  • Phone: 205-306-4491
  • Fax:
Mailing address:
  • Phone: 205-306-4491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0116034361
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: