Healthcare Provider Details

I. General information

NPI: 1568924611
Provider Name (Legal Business Name): DR. IAN DANIEL THISTLETHWAITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS ST
CHARLESTON WV
25301-1326
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE STE B-16
CHARLESTON WV
25304-1223
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5432
  • Fax:
Mailing address:
  • Phone: 304-388-5848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number33206
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33206
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA198420
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number330677
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: