Healthcare Provider Details

I. General information

NPI: 1699774315
Provider Name (Legal Business Name): MICHELLE LEIGH ENDICOTT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 KANAWHA AVE SW
SOUTH CHARLESTON WV
25309-1207
US

IV. Provider business mailing address

4815 KANAWHA AVE SW
SOUTH CHARLESTON WV
25309-1207
US

V. Phone/Fax

Practice location:
  • Phone: 304-768-4567
  • Fax: 304-768-2277
Mailing address:
  • Phone: 304-768-4567
  • Fax: 304-768-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2097
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: