1336146653 NPI number — DR. BONNIE K WHITE MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336146653 NPI number — DR. BONNIE K WHITE MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WHITE

Provider First Name:

BONNIE

Provider Middle Name:

K

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1336146653

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/17/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6210 SAINT ANDREWS CT

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

PONTE VEDRA BEACH

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

32082-2063

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

904-273-8039

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1100 SAWGRASS VILLAGE DR

Provider Second Line Business Practice Location Address:

SUITE 100

Provider Business Practice Location Address City Name:

PONTE VEDRA BEACH

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

32082-5048

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

904-285-9355

Provider Business Practice Location Address Fax Number:

904-285-7442

Provider Enumeration Date:

07/01/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  ME99063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X , with the licence number: 35062590 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1892968001 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: OC07700 . This is a "NATIONWIDE HEALTH PLANS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 0859110 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 341106740029 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 83307 . This is a "PHCS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 1006360 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: R62590 . This is a "SUMMA CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000127390 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 4211817 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 53013 . This is a "QUAL CHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".