Provider Demographics
NPI:1336170877
Name:WHITE, MARVIN (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11161 CRENSHAW BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2336
Mailing Address - Country:US
Mailing Address - Phone:310-419-1067
Mailing Address - Fax:310-419-1067
Practice Address - Street 1:11161 CRENSHAW BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-2336
Practice Address - Country:US
Practice Address - Phone:310-419-1067
Practice Address - Fax:310-419-1067
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39975207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE56880Medicare UPIN
CAA39975AMedicare PIN