Provider Demographics
NPI:1104995570
Name:WHITE, JEFFREY WADE (OD)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WADE
Last Name:WHITE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N IRWIN ST
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3813
Mailing Address - Country:US
Mailing Address - Phone:559-584-1630
Mailing Address - Fax:559-584-1757
Practice Address - Street 1:715 N IRWIN ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3813
Practice Address - Country:US
Practice Address - Phone:559-584-1630
Practice Address - Fax:559-584-1757
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8896T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0088960Medicaid
CASD0088960Medicaid
CAT91225Medicare UPIN