Provider Demographics
NPI:1144363458
Name:WHITE, MATTIE DAVIS (MD)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:DAVIS
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE STE 239
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-7034
Mailing Address - Country:US
Mailing Address - Phone:202-547-4850
Mailing Address - Fax:202-610-7147
Practice Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE STE 239
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7034
Practice Address - Country:US
Practice Address - Phone:202-547-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00376052084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC092200900Medicaid
DC2084P0804XOtherTAXONOMY CODE