Provider Demographics
NPI:1396765376
Name:WHITE, VERNON (MD)
Entity type:Individual
Prefix:
First Name:VERNON
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 1:589 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5056
Mailing Address - Country:US
Mailing Address - Phone:801-429-2000
Mailing Address - Fax:801-429-2001
Practice Address - Street 1:589 SOUTH STATE STREET
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5056
Practice Address - Country:US
Practice Address - Phone:801-429-2000
Practice Address - Fax:801-429-2001
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT186968-1205207Q00000X
UT1869681205207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0100201OtherUNITED HEALTHCARE
UT29088OtherCHIP MEDICAID/PEHP
UT870515716WH1OtherEMIA
UT29088OtherPEHP
UT870515716OtherGEHA
UT10983OtherMEDICAID LICENSE #
UT870515716004Medicaid
UT4256745OtherAETNA
UT870515716OtherBEECH STREET CORP
UT2741OtherDMBA
UTQM0000023756OtherALTIUS
UT107005500101OtherSELECT HEALTH
UT870515716018Medicaid
UT870515716OtherGEHA
UT29088OtherCHIP MEDICAID/PEHP