Healthcare Provider Details

I. General information

NPI: 1063523512
Provider Name (Legal Business Name): NICHOLAS CASSIS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MORRIS ST SUITE 300
CHARLESTON WV
25301-1842
US

IV. Provider business mailing address

415 MORRIS ST SUITE 300
CHARLESTON WV
25301-1842
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-6303
  • Fax: 304-345-6305
Mailing address:
  • Phone: 304-345-6303
  • Fax: 304-345-6305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number11251
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: