Healthcare Provider Details

I. General information

NPI: 1033167630
Provider Name (Legal Business Name): THOMAS F WILSHIRE III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL PLZ
GRAFTON WV
26354-1283
US

IV. Provider business mailing address

1893 GRAFTON RD
MORGANTOWN WV
26508-3817
US

V. Phone/Fax

Practice location:
  • Phone: 304-265-7406
  • Fax:
Mailing address:
  • Phone: 304-296-3741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1865
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: