Provider Demographics
NPI:1538108774
Name:WHITE, KELLY E (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
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:PO BOX 9600
Mailing Address - Street 2:DEPT 09-038
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-9600
Mailing Address - Country:US
Mailing Address - Phone:877-243-8416
Mailing Address - Fax:
Practice Address - Street 1:1453 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:RADIOLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-6800
Practice Address - Country:US
Practice Address - Phone:318-681-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD0205312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1672050Medicaid
LA1672050Medicaid
LA5W324B134Medicare ID - Type Unspecified