Healthcare Provider Details

I. General information

NPI: 1790782753
Provider Name (Legal Business Name): JAMES WILLIAM ENDICOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 MINGO ST
KERMIT WV
25674-0430
US

IV. Provider business mailing address

PO BOX 430
KERMIT WV
25674-0430
US

V. Phone/Fax

Practice location:
  • Phone: 304-393-4303
  • Fax: 304-393-3254
Mailing address:
  • Phone: 304-393-4303
  • Fax: 304-393-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14258
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: