1083615249 NPI number — DR. JAMES P. DEHAVEN M.D.

Table of content: (NPI 1083817563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083615249 NPI number — DR. JAMES P. DEHAVEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEHAVEN
Provider First Name:
JAMES
Provider Middle Name:
P.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083615249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
176 DAWKINS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24901-9302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-793-9564
Provider Business Mailing Address Fax Number:
334-671-8907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
176 DAWKINS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24901-9302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-645-6083
Provider Business Practice Location Address Fax Number:
304-645-1439
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  14868 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 515-21772 . This is a "BCBS OF AL- 4300 W. MAIN" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-21771 . This is a "BCBS OF AL- 1500 ROSS CL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009938927 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009956355 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009956365 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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