Provider Demographics
NPI:1265492797
Name:NEVILLE, JOHN WALLACE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALLACE
Last Name:NEVILLE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1100 GROSSCUP AVE
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-3120
Mailing Address - Country:US
Mailing Address - Phone:304-768-8811
Mailing Address - Fax:304-768-4072
Practice Address - Street 1:3752 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-757-3131
Practice Address - Fax:304-757-7718
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-12-23
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Provider Licenses
StateLicense IDTaxonomies
WV17801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9156433OtherGROUP MEDICARE
F84460Medicare UPIN
WV9156433OtherGROUP MEDICARE