Basic Information
| Provider Information | |||||||||
| NPI: | 1558365171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | 200 POCAHONTAS TRAIL | ||||||||
| City: | WHITE SULPHUR SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249860457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045365030 | ||||||||
| FaxNumber: | 3045365031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 MAIN ST | ||||||||
| Address2: | STE A | ||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044388561 | ||||||||
| FaxNumber: | 3044386754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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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 | 696 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0102050099 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0049368000 | 05 | WV | MEDICAID | 1558365171 | 05 | VA | MEDICAID |