Individual
NUMBEREYE PRE FUBARA NUMBERE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MBBS
Contact information
Practice address
327 MEDICAL PARK DR, BRIDGEPORT, WV 26330-9006
(681) 342-1000
Mailing address
PO BOX 775, MORGANTOWN, WV 26507-0775
(800) 541-4009
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
34345
WV
367500000X
Certified Registered Nurse Anesthetist
34345
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
39
—
NY
Enumeration date
07/31/2017
Last updated
11/12/2025
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