Healthcare Provider Details

I. General information

NPI: 1164658118
Provider Name (Legal Business Name): JOSEPH CLARY KIRKPATRICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 01/22/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 103 SUPPLY STREET
GARY WV
24836-0507
US

IV. Provider business mailing address

PO BOX 507 RR 103 SUPPLY STREET,
GARY WV
24836-0507
US

V. Phone/Fax

Practice location:
  • Phone: 304-448-2101
  • Fax: 304-448-3217
Mailing address:
  • Phone: 304-448-2101
  • Fax: 304-448-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number0102206396
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102206396
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2675
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: