Healthcare Provider Details

I. General information

NPI: 1619902822
Provider Name (Legal Business Name): DR. ROBERT WILLIAM POWELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PIKE ST
SHINNSTON WV
26431-1405
US

IV. Provider business mailing address

401 PIKE ST
SHINNSTON WV
26431-1405
US

V. Phone/Fax

Practice location:
  • Phone: 304-592-1500
  • Fax: 304-592-1343
Mailing address:
  • Phone: 304-592-1500
  • Fax: 304-592-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number763OD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: