Provider Demographics
NPI:1902059843
Name:CLARK, DEREK DWIGHT (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:DWIGHT
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EASTGATE PLZ
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-9544
Mailing Address - Country:US
Mailing Address - Phone:304-225-0910
Mailing Address - Fax:304-225-0949
Practice Address - Street 1:116 MARKET ST
Practice Address - Street 2:
Practice Address - City:MANNINGTON
Practice Address - State:WV
Practice Address - Zip Code:26582-1131
Practice Address - Country:US
Practice Address - Phone:304-986-1568
Practice Address - Fax:304-986-1373
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4253981Medicare PIN