Provider Demographics
NPI:1477559631
Name:WHITE, MARK WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:103 MEMORIAL MEDICAL PKWY STE 125
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5672
Practice Address - Country:US
Practice Address - Phone:386-274-0250
Practice Address - Fax:386-274-0269
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME75474208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107281OtherFHCP
FLP01102622OtherRAILROAD MEDICARE
FLE5704XMedicare PIN
FL107281OtherFHCP