1063267128 NPI number — WHITE-WILSON MEDICAL CENTER, P.A.

Table of content: (NPI 1063267128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063267128 NPI number — WHITE-WILSON MEDICAL CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE-WILSON MEDICAL CENTER, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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 Information

NPI Number:
1063267128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 MAR WALT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547-6707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-863-8299
Provider Business Mailing Address Fax Number:
850-863-4152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 US HIGHWAY 331 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEFUNIAK SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32435-3379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-892-3366
Provider Business Practice Location Address Fax Number:
833-451-2226
Provider Enumeration Date:
04/22/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PERSAUD
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
850-863-8150

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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