Provider Demographics
NPI:1316912892
Name:WHITE, MATTIE (MD)
Entity type:Individual
Prefix:MRS
First Name:MATTIE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3197 PORTIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-2023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3197 PORTIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-2023
Practice Address - Country:US
Practice Address - Phone:618-713-3847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008014947207Q00000X
IL036103546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316912892Medicaid
ILCB3700OtherRAILROAD GROUP NUMBER
IL659580OtherMEDICARE GROUP
ILP00189155OtherRAILROAD MEDICARE
ILK04489OtherUMWA PIN
IL10007459OtherBCBS GROUP NUMBER
IL036103546Medicaid
IL460661OtherHEALTHLINK PROV NUMBER
ILK04489Medicare PIN
IL460661OtherHEALTHLINK PROV NUMBER