MEDICARE: DR. IAN DANIEL THISTLETHWAITE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	33206	WV
2	207R00000X	Internal Medicine Physician	33206	WV
3	2084P0800X	Psychiatry Physician	A198420	CA
4	2084P0800X	Psychiatry Physician	330677	NY

General Provider Information

NPI Number	:	1568924611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IAN DANIEL THISTLETHWAITE

Provider Business Mailing Address
First Line	:	3100 MACCORKLE AVE SE STE B-16
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-1223
Country	:	US
Telephone Number	:	304-388-5848
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 MORRIS ST
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1326
Country	:	US
Telephone Number	:	304-388-5432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2019
Last Update Date	:	12/02/2025

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