Provider Demographics
NPI:1740856848
Name:SHOWALTER, DERRICK JEROME
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JEROME
Last Name:SHOWALTER
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 1:1122 MERCER ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-3030
Mailing Address - Country:US
Mailing Address - Phone:304-800-0544
Mailing Address - Fax:
Practice Address - Street 1:1122 MERCER ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3030
Practice Address - Country:US
Practice Address - Phone:304-800-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF341538172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver