Provider Demographics
NPI:1104821826
Name:WHITE, JOHN TODD (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TODD
Last Name:WHITE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:TODD
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:729 E SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-3512
Mailing Address - Country:US
Mailing Address - Phone:719-547-9119
Mailing Address - Fax:719-547-7555
Practice Address - Street 1:729 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-3512
Practice Address - Country:US
Practice Address - Phone:719-547-9119
Practice Address - Fax:719-547-7555
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92172261Medicaid
COP00869198OtherMCR RAILROAD
COCOA100766Medicare UPIN
COI03820Medicare UPIN