Provider Demographics
NPI:1144215666
Name:GLASSCOCK, TELITHA DONET (DO)
Entity Type:Individual
Prefix:DR
First Name:TELITHA
Middle Name:DONET
Last Name:GLASSCOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:401 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2300
Mailing Address - Country:US
Mailing Address - Phone:304-431-5041
Mailing Address - Fax:304-425-6121
Practice Address - Street 1:401 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2300
Practice Address - Country:US
Practice Address - Phone:304-431-5041
Practice Address - Fax:304-425-6121
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVH00781Medicare UPIN
WV0886933Medicare PIN
WV9333111Medicare PIN