Healthcare Provider Details

I. General information

NPI: 1538452438
Provider Name (Legal Business Name): JONATHAN M WHITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 6TH AVE
MONTGOMERY WV
25136-2199
US

IV. Provider business mailing address

PO BOX 270
MONTGOMERY WV
25136-0270
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-5151
  • Fax: 304-442-7494
Mailing address:
  • Phone: 304-442-5151
  • Fax: 304-442-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25777
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25777
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: