Healthcare Provider Details

I. General information

NPI: 1447218458
Provider Name (Legal Business Name): SERGIO CAPUNO MACATANGAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 03/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 MAIN ST
WAR WV
24892-0250
US

IV. Provider business mailing address

PO BOX 250 11710 MAIN ST
WAR WV
24892-0250
US

V. Phone/Fax

Practice location:
  • Phone: 304-875-2299
  • Fax: 304-875-2205
Mailing address:
  • Phone: 304-875-2299
  • Fax: 304-875-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number13158
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: