Provider Demographics
NPI:1215923495
Name:WHITE, JOHN BOWMAN III (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BOWMAN
Last Name:WHITE
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 TEAYS VALLEY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9772
Mailing Address - Country:US
Mailing Address - Phone:304-757-5880
Mailing Address - Fax:304-757-5881
Practice Address - Street 1:3860 TEAYS VALLEY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9772
Practice Address - Country:US
Practice Address - Phone:304-757-5880
Practice Address - Fax:304-757-5881
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2011-03-17
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
WV00313213EP1101X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0099970000Medicaid
WV0099970000Medicaid
WVWH0797652Medicare ID - Type Unspecified
WV4468770001Medicare NSC