Healthcare Provider Details

I. General information

NPI: 1821049339
Provider Name (Legal Business Name): ISIDRO A AMIGO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 ROSE ST
GRAFTON WV
26354-1678
US

IV. Provider business mailing address

PO BOX 42738
TOWSON MD
21284-2738
US

V. Phone/Fax

Practice location:
  • Phone: 304-265-0095
  • Fax: 304-265-6215
Mailing address:
  • Phone: 844-468-9502
  • Fax: 317-663-6054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34002976
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1181
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: