Provider Demographics
NPI:1336118587
Name:MCCORMICK, JEFFREY REED (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:REED
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 KANAWHA BLVD W
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-2536
Mailing Address - Country:US
Mailing Address - Phone:304-768-8523
Mailing Address - Fax:304-941-1918
Practice Address - Street 1:1606 KANAWHA BLVD W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2536
Practice Address - Country:US
Practice Address - Phone:304-768-8523
Practice Address - Fax:304-941-1918
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0048360000Medicaid
WV0048360000Medicaid
0848562Medicare ID - Type Unspecified
WV0048360000Medicaid