Provider Demographics
NPI:1295849982
Name:HANNAH, JOHN WALTON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTON
Last Name:HANNAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:4610 KANAWHA AVE SW STE 401
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1367
Practice Address - Country:US
Practice Address - Phone:304-768-7368
Practice Address - Fax:304-768-1829
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17872208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID
WV000023003OtherMTN ST BCBS
WV4502350OtherAETNA
WV0130338000Medicaid
WVB441OtherGROUP MEDICARE