Provider Demographics
NPI:1245380831
Name:JOSEPH J DEPETRO III MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JOSEPH J DEPETRO III MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEPETRO
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:304-737-0321
Mailing Address - Street 1:PO BOX 6691
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0913
Mailing Address - Country:US
Mailing Address - Phone:304-233-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:69 8TH ST
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-1605
Practice Address - Country:US
Practice Address - Phone:304-737-0321
Practice Address - Fax:304-737-2979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9324031Medicare ID - Type Unspecified