Provider Demographics
NPI:1427158815
Name:WHITE, THOMAS ELWOOD (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ELWOOD
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:P O BOX 3129
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-3129
Mailing Address - Country:US
Mailing Address - Phone:719-395-8632
Mailing Address - Fax:719-395-4971
Practice Address - Street 1:36 OAK STREET
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211
Practice Address - Country:US
Practice Address - Phone:719-395-8632
Practice Address - Fax:719-395-4971
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01338573Medicaid
G27029Medicare UPIN
D4348Medicare ID - Type Unspecified