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General NPI Number Information
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NPI Number | 1912933151
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Entity Type | Individual
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Provider Name | CHANDOS DEWAYNE TACKETT MD
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Gender | Male
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Dates
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Enumeration Date | 06/22/2006
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Last Update Date | 04/23/2025
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Provider Practice Location Address
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Address Line | 3075 US ROUTE 60 STE A110
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City | HUNTINGTON
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State | WV
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Zip | 25705-8859
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Country | US
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Telephone | 304-528-4600
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Fax |
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Provider Business Mailing Address
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Address Line | 3075 US ROUTE 60
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City | HUNTINGTON
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State | WV
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Zip | 25705-8859
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Country | US
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Telephone | 304-528-4600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 18209
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License Number State | WV
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