1619960176 NPI number — AMY ANNE VASILAKIS-DONZELLA DO

Table of content: AMY ANNE VASILAKIS-DONZELLA DO (NPI 1619960176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619960176 NPI number — AMY ANNE VASILAKIS-DONZELLA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VASILAKIS-DONZELLA
Provider First Name:
AMY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VASILAKIS-DONZELLA
Provider Other First Name:
AMY
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619960176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1315 MT. DECHANTAL ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26003-6392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-243-7117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 MT. DECHANTAL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-6392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-243-7117
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1899 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2410064 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1899 . This is a "HEALTH PLAN OF UPPER OH V" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21502391100 . This is a "OHIO BWC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 001718181 . This is a "MOUNTAIN STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 55035705700 . This is a "WV COMPENSATION" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1809463000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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