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General NPI Number Information
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NPI Number | 1316912892
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Entity Type | Individual
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Provider Name | MATTIE WHITE MD
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Gender | Female
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Dates
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Enumeration Date | 02/20/2006
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Last Update Date | 10/17/2017
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Provider Practice Location Address
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Address Line | 3197 PORTIS AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63116-2023
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Country | US
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Telephone | 618-713-3847
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Fax |
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Provider Business Mailing Address
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Address Line | 3197 PORTIS AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63116-2023
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2008014947
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036103546
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License Number State | IL
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