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General NPI Number Information
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NPI Number | 1639169485
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Entity Type | Individual
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Provider Name | GORDON ELLIS WHITE II M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/24/2005
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Last Update Date | 06/08/2021
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Provider Practice Location Address
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Address Line | 1900 E MAIN ST
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City | DANVILLE
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State | IL
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Zip | 61832-5100
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Country | US
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Telephone | 318-801-4070
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Fax | 318-554-4807
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Provider Business Mailing Address
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Address Line | 1900 E MAIN ST
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City | DANVILLE
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State | IL
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Zip | 61832-5100
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Country | US
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Telephone | 318-801-4070
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Fax | 318-554-4807
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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 | 025398
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number | 025398
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License Number State | LA
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