Provider Demographics
NPI:1285877498
Name:WHITE, STEPHEN JEROME (IDMT)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JEROME
Last Name:WHITE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 COMMUNITY AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214
Mailing Address - Country:US
Mailing Address - Phone:971-244-0286
Mailing Address - Fax:
Practice Address - Street 1:374 MSGS/SGNE
Practice Address - Street 2:UNIT 5071
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328
Practice Address - Country:US
Practice Address - Phone:971-244-0286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians