=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992748180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK DOUGLAS WHITE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 01/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 PETER JEFFERSON PKWY STE 290
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22911-8848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-297-7140
-----------------------------------------------------
Fax | 434-297-7235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5495 MAPLE LANE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25840-9589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-574-1888
-----------------------------------------------------
Fax | 304-574-1891
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 14161
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0101264388
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------