Provider Demographics
NPI:1548892532
Name:MOUNTAIN STATE DIABETES PLLC
Entity type:Organization
Organization Name:MOUNTAIN STATE DIABETES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:PICKERING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:877-377-8427
Mailing Address - Street 1:1900 GARFIELD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-2565
Mailing Address - Country:US
Mailing Address - Phone:877-377-8427
Mailing Address - Fax:304-699-0396
Practice Address - Street 1:1900 GARFIELD AVE STE A
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-2565
Practice Address - Country:US
Practice Address - Phone:877-377-8427
Practice Address - Fax:304-699-0396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty