Basic Information
| Provider Information | |||||||||
| NPI: | 1083615249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEHAVEN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 176 DAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249019302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Practice Location | |||||||||
| Address1: | 176 DAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249019302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046456083 | ||||||||
| FaxNumber: | 3046451439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 14868 | WV | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 515-21772 | 01 | AL | BCBS OF AL- 4300 W. MAIN | OTHER | 515-21771 | 01 | AL | BCBS OF AL- 1500 ROSS CL | OTHER | 009938927 | 05 | AL | MEDICAID | 009956355 | 05 | AL | MEDICAID | 009956365 | 05 | AL | MEDICAID |