Provider Demographics
NPI:1649498080
Name:FACELLO, DAVID W (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:FACELLO
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 1:812 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3181
Mailing Address - Country:US
Mailing Address - Phone:304-637-3456
Mailing Address - Fax:
Practice Address - Street 1:812 GORMAN AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3181
Practice Address - Country:US
Practice Address - Phone:304-637-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11410207Q00000X
AZ007768207Q00000X
IADO-05251207Q00000X
IL036147010207Q00000X
MN64331207Q00000X
NE1868207Q00000X
NH19103207Q00000X
WI31-321207Q00000X
KS05-41277207Q00000X
NC2018-02840207Q00000X
WV2131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV3430BMedicare PIN
WV3403BMedicare PIN