Healthcare Provider Details

I. General information

NPI: 1689069700
Provider Name (Legal Business Name): JEREMY DANIEL HUSTEAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DRIVE ROOM 4601
MORGANTOWN WV
26506-8121
US

IV. Provider business mailing address

1 MEDICAL CENTER DRIVE, ROOM 4601
MORGANTOWN WV
26506-8121
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-5323
  • Fax: 304-293-8724
Mailing address:
  • Phone: 304-293-5323
  • Fax: 304-293-8724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number27683
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number27683
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number27683
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: