Provider Demographics
NPI:1073856225
Name:WHITE, BROC CODI (MD)
Entity type:Individual
Prefix:MR
First Name:BROC
Middle Name:CODI
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3431
Mailing Address - Country:US
Mailing Address - Phone:307-332-2941
Mailing Address - Fax:307-332-1920
Practice Address - Street 1:745 BUENA VISTA DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3431
Practice Address - Country:US
Practice Address - Phone:307-332-2941
Practice Address - Fax:307-332-1920
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10524A207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program