Healthcare Provider Details

I. General information

NPI: 1255788758
Provider Name (Legal Business Name): BRANDON M LINGENFELTER DO PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 12TH STREET EXT
PRINCETON WV
24740-2300
US

IV. Provider business mailing address

411 12TH STREET EXT
PRINCETON WV
24740-2300
US

V. Phone/Fax

Practice location:
  • Phone: 681-282-5591
  • Fax: 681-282-5593
Mailing address:
  • Phone: 681-282-5591
  • Fax: 681-282-5593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3064
License Number StateWV

VIII. Authorized Official

Name: BRANDON MICHAEL LINGENFELTER
Title or Position: OWNER
Credential: D.O.
Phone: 681-282-5591