Provider Demographics
NPI:1285904417
Name:WITHERSTY, DAVID J (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:WITHERSTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 N KANAWHA ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2713
Mailing Address - Country:US
Mailing Address - Phone:304-472-0005
Mailing Address - Fax:888-606-1919
Practice Address - Street 1:13 N KANAWHA ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2713
Practice Address - Country:US
Practice Address - Phone:304-472-0005
Practice Address - Fax:888-606-1919
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09270103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV09270OtherWV BOARD OF MEDICINE