Healthcare Provider Details

I. General information

NPI: 1083644702
Provider Name (Legal Business Name): SUBHASH A VYAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 1/2 WEST SECOND AVENUE
WILLIAMSON WV
25661-3506
US

IV. Provider business mailing address

P.O. BOX 1599 22 1/2 WEST SECOND AVENUE
WILLIAMSON WV
25661-1599
US

V. Phone/Fax

Practice location:
  • Phone: 304-235-0222
  • Fax: 304-235-4343
Mailing address:
  • Phone: 304-235-0222
  • Fax: 304-235-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number12356
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: