Provider Demographics
NPI:1720153174
Name:DEMARINO, DANIEL J
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:DEMARINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 EMILY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-5505
Mailing Address - Country:US
Mailing Address - Phone:304-624-5642
Mailing Address - Fax:304-624-1599
Practice Address - Street 1:104 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2193
Practice Address - Country:US
Practice Address - Phone:304-624-5642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV804D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150956000Medicaid
U28304Medicare UPIN
WV0546720001Medicare NSC
WV0150956000Medicaid