Healthcare Provider Details

I. General information

NPI: 1215042593
Provider Name (Legal Business Name): GORDON F PRESCOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 NEW HOPE RD STE 7
PRINCETON WV
24740
US

IV. Provider business mailing address

118 12TH STREET EXT
PRINCETON WV
24740-2352
US

V. Phone/Fax

Practice location:
  • Phone: 304-431-7200
  • Fax:
Mailing address:
  • Phone: 304-487-7936
  • Fax: 304-487-7835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10242
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: