Provider Demographics
NPI:1972598191
Name:TRAVIS, JOHN TODD (ATC, MS, PT)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:TODD
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:ATC, MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2382 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WV
Mailing Address - Zip Code:26426-7521
Mailing Address - Country:US
Mailing Address - Phone:304-782-1052
Mailing Address - Fax:304-782-1053
Practice Address - Street 1:2382 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WV
Practice Address - Zip Code:26426-7521
Practice Address - Country:US
Practice Address - Phone:304-782-1052
Practice Address - Fax:304-782-1053
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV987208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156442000Medicaid
WV650010940OtherRAILROAD MEDICARE
WV0156442000Medicaid
0718922Medicare PIN
WV0718922Medicare PIN
WVS01235Medicare PIN