1811977937 NPI number — DR. WALLACE TODD COHRON OD

Table of content: DR. WALLACE TODD COHRON OD (NPI 1811977937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811977937 NPI number — DR. WALLACE TODD COHRON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COHRON
Provider First Name:
WALLACE
Provider Middle Name:
TODD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1811977937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 W GL SMITH ST
Provider Second Line Business Mailing Address:
PO BOX 1007
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42261-1007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-526-6800
Provider Business Mailing Address Fax Number:
270-526-5462

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W GL SMITH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42261-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-526-6800
Provider Business Practice Location Address Fax Number:
270-526-5462
Provider Enumeration Date:
01/17/2006

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: 152W00000X , with the licence number:  1372DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000041898 . This is a "BLUE CROSS/BLU SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1524171 . This is a "UMWA FUNDS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 410032987 . This is a "RAILROAD MEDICARE IN HART" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 410032989 . This is a "RAILROAD MEDICARE IN MORG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000041897 . This is a "BLUE CROSS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 02144 . This is a "SPECTERA IN HARTFORD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 02145 . This is a "SPECTERA IN MORGANTOWN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77013720 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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