MEDICARE: JACK DOTY III PA

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	363A00000X	Physician Assistant	1970	WV

General Provider Information

NPI Number	:	1801254412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK DOTY III PA

Provider Business Mailing Address
First Line	:	7400 LYNN AVE
Second Line	:
City	:	HAMLIN
State	:	WV
Zip	:	25523-1138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5027 HELENA AVE
Second Line	:
City	:	DELBARTON
State	:	WV
Zip	:	25670-1301
Country	:	US
Telephone Number	:	304-475-1761
Fax Number	:	304-475-1762

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

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	12/09/2025

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Directions to “ JACK DOTY III PA” Practice Location

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