Provider Demographics
NPI:1447329719
Name:WHITE, KEVIN PATRICK (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
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 1:3303 SW BOND AVE # CH5D
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-1375
Mailing Address - Fax:503-494-6844
Practice Address - Street 1:3303 SW BOND AVE # CH5D
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-1375
Practice Address - Fax:503-494-6844
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26727207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240056Medicaid