Healthcare Provider Details

I. General information

NPI: 1295840593
Provider Name (Legal Business Name): ENRIQUE COLLANTES STA. ANA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HOSPITAL DR
HURRICANE WV
25526-8712
US

IV. Provider business mailing address

2585 3RD AVE
HUNTINGTON WV
25703-1642
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-8683
  • Fax: 304-757-8684
Mailing address:
  • Phone: 304-697-1396
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11628
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: