Provider Demographics
NPI:1437429198
Name:DALTON, DEREK (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:DALTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 945
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-0945
Mailing Address - Country:US
Mailing Address - Phone:304-928-1446
Mailing Address - Fax:
Practice Address - Street 1:560 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508
Practice Address - Country:US
Practice Address - Phone:304-928-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2693183OtherBCBS
WV3810023134Medicaid
WV3810023134Medicaid