Provider Demographics
NPI:1225084437
Name:HAMILTON, J. MARK (PT)
Entity Type:Individual
Prefix:MR
First Name:J. MARK
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-1020
Mailing Address - Country:US
Mailing Address - Phone:304-538-7971
Mailing Address - Fax:304-538-7971
Practice Address - Street 1:739 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOOREFIELD
Practice Address - State:WV
Practice Address - Zip Code:26836-1020
Practice Address - Country:US
Practice Address - Phone:304-538-7971
Practice Address - Fax:304-538-7971
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV11533767OtherCAQH
WV154117OtherAPTA MEMBER
WV36292OtherOPTIMUM
WV0157850000Medicaid
WV292898OtherMAMSI
WV36292OtherOPTIMUM