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NPI Code Detail

MEDICARE: DEREK OMAR WHITE P.T.

MEDICARE: DEREK OMAR WHITE P.T.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist346435-2401UT
2225100000XPhysical TherapistPT00010324WA

General Provider Information

NPI Number : 1417083064
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEREK OMAR WHITE P.T.
Provider Business Mailing Address
First Line : 529 W 1200 N
Second Line :
City : OREM
State : UT
Zip : 84057-2948
Country : US
Telephone Number : 801-226-5565
Fax Number : 801-226-5565
Provider Business Practice Location Address
First Line : 50 E 9000 S
Second Line :
City : SANDY
State : UT
Zip : 84070-2201
Country : US
Telephone Number : 801-561-9839
Fax Number : 801-352-0027
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/26/2007
Last Update Date : 07/08/2007

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