Provider Demographics
NPI:1184803330
Name:COLLIVER, ETHAN B (DO)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:B
Last Name:COLLIVER
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 1:122 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2312
Mailing Address - Country:US
Mailing Address - Phone:304-425-7127
Mailing Address - Fax:304-487-7235
Practice Address - Street 1:122 12TH ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2312
Practice Address - Country:US
Practice Address - Phone:304-425-7127
Practice Address - Fax:304-487-7235
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202357208100000X
WV4641208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1184803330Medicaid
P00754384Medicare PIN
VA1184803330Medicaid