Provider Demographics
NPI:1063415982
Name:DEMARINO, JOHN W JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:DEMARINO
Suffix:JR
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 1:1901 TATE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1109
Mailing Address - Country:US
Mailing Address - Phone:434-200-3015
Mailing Address - Fax:434-200-7377
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:434-200-3015
Practice Address - Fax:434-200-7377
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101268941207L00000X
CT040076207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001400762Medicaid