Provider Demographics
NPI:1609905462
Name:STAPLETON, JEREMY RYAN (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:STAPLETON
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 1:401 DIVISION ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1455
Mailing Address - Country:US
Mailing Address - Phone:304-342-0821
Mailing Address - Fax:304-345-6679
Practice Address - Street 1:401 DIVISION ST STE 205
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1455
Practice Address - Country:US
Practice Address - Phone:304-342-0821
Practice Address - Fax:304-345-6679
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03019207R00000X, 208M00000X
WV2126207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY107365OtherSIHO - NIS
KY7100080660Medicaid
KY000000628054OtherANTHEM - NIS
KY000028412UOtherHUMANA - NIS
KY2546966OtherCIGNA - NIS
WV3810019300Medicaid
KY3733152000OtherPASSPORT ADVANTAGE - NIS
KY50025382OtherPASSPORT - NIS
IN200963400Medicaid
KY00533182Medicare PIN
KY000000628054OtherANTHEM - NIS
WV1609905462Medicare UPIN
IN200963400Medicaid
KY3733152000OtherPASSPORT ADVANTAGE - NIS