Healthcare Provider Details

I. General information

NPI: 1780712752
Provider Name (Legal Business Name): JOEDY L DARISTOTLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 LOCUST AVE
FAIRMONT WV
26554-1321
US

IV. Provider business mailing address

1712 LOCUST AVE
FAIRMONT WV
26554-1321
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-6157
  • Fax: 304-366-0177
Mailing address:
  • Phone: 304-366-6157
  • Fax: 304-366-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberPT21491
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberWV14772
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: