Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2360 | WV |
N | 207Q00000X | Family Doctor | 34007332 | OH |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 27036 | MT |
NPI | 1336192269 |
---|---|
Provider Name | Dr. J. Derek Hollingsworth |
First Address | Millwood, WV 25262-8100 |
Second Address | Millwood, WV 25262-8100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2006 |
Last Update Date | 19/12/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000185452 | UNISON MEDICAID (01) | OH |
000000205910 | ANTHEM BCBS (01) | |
001714124 | MOUNTAIN STATE BCBS (01) | |
1336192269 | NPI (01) | |
2246895 | MOLINA MEDICAID (01) | OH |
27036 | STATE LICENSE (01) | MT |
3002978000 | (05) | WV |
516066972 | TRI CARE (01) | OH |
930106977 | RR MEDICARE (01) |