Provider Demographics
NPI:1336192269
Name:HOLLINGSWORTH, J. DEREK (DO)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:DEREK
Last Name:HOLLINGSWORTH
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 1:6775 POINT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:MILLWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25262-8100
Mailing Address - Country:US
Mailing Address - Phone:304-273-0112
Mailing Address - Fax:304-273-0115
Practice Address - Street 1:6775 POINT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:MILLWOOD
Practice Address - State:WV
Practice Address - Zip Code:25262-8100
Practice Address - Country:US
Practice Address - Phone:304-273-0112
Practice Address - Fax:304-273-0115
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007332207Q00000X
WV2360207Q00000X
MT27036207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2246895OtherMOLINA MEDICAID
OH000000185452OtherUNISON MEDICAID
WV3002978000Medicaid
MT27036OtherSTATE LICENSE
930106977OtherRR MEDICARE
1336192269OtherNPI
001714124OtherMOUNTAIN STATE BCBS
OH516066972OtherTRI CARE
000000205910OtherANTHEM BCBS
930106977OtherRR MEDICARE
WV3002978000Medicaid