Healthcare Provider Details

I. General information

NPI: 1891180741
Provider Name (Legal Business Name): DEREK GOFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 6TH AVE
HUNTINGTON WV
25701-2420
US

IV. Provider business mailing address

1415 6TH AVE
HUNTINGTON WV
25701-2420
US

V. Phone/Fax

Practice location:
  • Phone: 304-523-1142
  • Fax: 304-523-2966
Mailing address:
  • Phone: 304-523-1142
  • Fax: 304-523-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number3553
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: