Provider Demographics
NPI:1902875057
Name:WHITE, JOHN S II
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:WHITE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 SUMMAR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3915
Mailing Address - Country:US
Mailing Address - Phone:731-423-1932
Mailing Address - Fax:731-410-0367
Practice Address - Street 1:294 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3915
Practice Address - Country:US
Practice Address - Phone:731-423-1932
Practice Address - Fax:731-410-0367
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD30788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3838679Medicaid
TN3838679Medicaid
TN103I089344Medicare PIN
TN080153243Medicare PIN