Provider Demographics
NPI:1609164227
Name:MUTO, DEIDRA FAWN (MD)
Entity type:Individual
Prefix:DR
First Name:DEIDRA
Middle Name:FAWN
Last Name:MUTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEIDRA
Other - Middle Name:FAWN
Other - Last Name:NAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:219 GEORGETOWN PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 GEORGETOWN PL
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-1871
Practice Address - Country:US
Practice Address - Phone:304-543-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-17
Last Update Date:2011-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21489207ZP0102X
SC21492207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVIL14305Medicare UPIN