Provider Demographics
NPI:1780712752
Name:DARISTOTLE, JOEDY L (MD)
Entity type:Individual
Prefix:
First Name:JOEDY
Middle Name:L
Last Name:DARISTOTLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1321
Mailing Address - Country:US
Mailing Address - Phone:304-366-6157
Mailing Address - Fax:304-366-0177
Practice Address - Street 1:1712 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1321
Practice Address - Country:US
Practice Address - Phone:304-366-6157
Practice Address - Fax:304-366-0177
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT21491207Y00000X
WVWV14772207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0041418000Medicaid
WV0041418000Medicaid
0660621Medicare PIN
WV6022731Medicare PIN