Provider Demographics
NPI:1396171419
Name:WHITE, KRISTIN (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3572
Mailing Address - Country:US
Mailing Address - Phone:843-248-4700
Mailing Address - Fax:877-322-0181
Practice Address - Street 1:1608 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3572
Practice Address - Country:US
Practice Address - Phone:843-248-4700
Practice Address - Fax:877-322-0181
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33577152W00000X
SC2369152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD23696Medicaid