Provider Demographics
NPI:1669437612
Name:WHITE, CHARLES A (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:WHITE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57392 M 51 S
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-9766
Mailing Address - Country:US
Mailing Address - Phone:269-782-4141
Mailing Address - Fax:269-783-1236
Practice Address - Street 1:57392 M 51 S
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-9766
Practice Address - Country:US
Practice Address - Phone:269-782-4141
Practice Address - Fax:269-783-1236
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002231A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100358190Medicaid
IN100358190Medicaid