Provider Demographics
NPI:1194963769
Name:HAMMACK, DERON JOHN (DO)
Entity type:Individual
Prefix:
First Name:DERON
Middle Name:JOHN
Last Name:HAMMACK
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 1:143 BEUHRING ST
Mailing Address - Street 2:
Mailing Address - City:LAVALETTE
Mailing Address - State:WV
Mailing Address - Zip Code:25535-8706
Mailing Address - Country:US
Mailing Address - Phone:304-525-7272
Mailing Address - Fax:304-525-7272
Practice Address - Street 1:143 BEUHRING ST
Practice Address - Street 2:
Practice Address - City:LAVALETTE
Practice Address - State:WV
Practice Address - Zip Code:25535-8706
Practice Address - Country:US
Practice Address - Phone:304-525-7272
Practice Address - Fax:304-525-7272
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV2487207Q00000X, 207P00000X
KYTP322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine