Healthcare Provider Details

I. General information

NPI: 1336192269
Provider Name (Legal Business Name): J. DEREK HOLLINGSWORTH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6775 POINT PLEASANT RD
MILLWOOD WV
25262-8100
US

IV. Provider business mailing address

6775 POINT PLEASANT RD
MILLWOOD WV
25262-8100
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-0112
  • Fax: 304-273-0115
Mailing address:
  • Phone: 304-273-0112
  • Fax: 304-273-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34007332
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2360
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number27036
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: