Provider Demographics
NPI:1215984661
Name:WHITE, PETER R (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:JTDM FAMILY PRACTICES LLC
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-586-8509
Practice Address - Street 1:801 PRO DR
Practice Address - Street 2:STE D1
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-3307
Practice Address - Country:US
Practice Address - Phone:419-394-3387
Practice Address - Fax:419-586-8509
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-072242208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1942630348OtherGROUP NPI- GRAND LAKE FAMILY & PEDIATRICS
OHH280560OtherMEDICARE INDIVIDUAL PTAN
OH9934723OtherMEDICARE GROUP PTAN
OH2016204Medicaid
OH2016204Medicaid