Provider Demographics
NPI:1063521292
Name:WHITE, DEANNA R (MD)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:R
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 HARDEN STREET EXT STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6894
Mailing Address - Country:US
Mailing Address - Phone:803-545-5016
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 320
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6896
Practice Address - Country:US
Practice Address - Phone:803-434-6771
Practice Address - Fax:803-434-3855
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19071207R00000X
SC40367207R00000X
TN36316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05233201Medicaid
SC406373Medicaid
MSC02394Medicare ID - Type Unspecified
MS05233201Medicaid