Provider Demographics
NPI:1538452438
Name:WHITE, JONATHAN M (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
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 270
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:WV
Mailing Address - Zip Code:25136-0270
Mailing Address - Country:US
Mailing Address - Phone:304-442-5151
Mailing Address - Fax:304-442-7494
Practice Address - Street 1:401 6TH AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136-2199
Practice Address - Country:US
Practice Address - Phone:304-442-5151
Practice Address - Fax:304-442-7494
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25777207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024049OtherMEDICAID GROUP
WV3810027356Medicaid
WVB441OtherMEDICARE GROUP
WVWV4211B441Medicare PIN