Basic Information
| Provider Information | |||||||||
| NPI: | 1336192269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLINGSWORTH | ||||||||
| FirstName: | J. | ||||||||
| MiddleName: | DEREK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6775 POINT PLEASANT RD | ||||||||
| Address2: | |||||||||
| City: | MILLWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252628100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042730112 | ||||||||
| FaxNumber: | 3042730115 | ||||||||
| Practice Location | |||||||||
| Address1: | 6775 POINT PLEASANT RD | ||||||||
| Address2: | |||||||||
| City: | MILLWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252628100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042730112 | ||||||||
| FaxNumber: | 3042730115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34007332 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2360 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 27036 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2246895 | 01 | OH | MOLINA MEDICAID | OTHER | 000000185452 | 01 | OH | UNISON MEDICAID | OTHER | 3002978000 | 05 | WV | MEDICAID | 27036 | 01 | MT | STATE LICENSE | OTHER | 930106977 | 01 | RR MEDICARE | OTHER | 1336192269 | 01 | NPI | OTHER | 001714124 | 01 | MOUNTAIN STATE BCBS | OTHER | 516066972 | 01 | OH | TRI CARE | OTHER | 000000205910 | 01 | ANTHEM BCBS | OTHER |