Provider Demographics
NPI:1902948722
Name:DERAIMO, DAVID JOSEPH (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:DERAIMO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4357
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-4357
Mailing Address - Country:US
Mailing Address - Phone:304-855-4529
Mailing Address - Fax:304-855-5112
Practice Address - Street 1:612 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508
Practice Address - Country:US
Practice Address - Phone:304-855-4529
Practice Address - Fax:304-855-5112
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV861111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001945851OtherBCBS
WV1071821OtherBRICKSTREET WORKERS COMP
633786OtherCOVENTRY ADVANTRA FREEDOM
0009267096OtherAETNA
WV3810008715Medicaid
0009267096OtherAETNA
WV9367441Medicare PIN