=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083805378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW P WHITE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 09/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2633 MARIN AVE
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94708-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-559-8469
-----------------------------------------------------
Fax | 650-724-3144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2633 MARIN AVE
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94708-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-559-8469
-----------------------------------------------------
Fax | 650-724-3144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A71577
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------