Basic Information
Provider Information | |||||||||
NPI: | 1033217914 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAMORA | ||||||||
FirstName: | ISMAEL | ||||||||
MiddleName: | ORTEGO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 236 | ||||||||
Address2: |   | ||||||||
City: | PT PLEASANT | ||||||||
State: | WV | ||||||||
PostalCode: | 255500236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046755188 | ||||||||
FaxNumber: | 3046755893 | ||||||||
Practice Location | |||||||||
Address1: | 2520 VALLEY DR | ||||||||
Address2: | SUITE # 116 | ||||||||
City: | PT PLEASANT | ||||||||
State: | WV | ||||||||
PostalCode: | 255502031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046755188 | ||||||||
FaxNumber: | 3046753811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 12/10/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 10222 | WV | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 000000504 | 01 | WV | BCBS | OTHER | 0076037000 | 05 | WV |   | MEDICAID | 0222664 | 05 | OH |   | MEDICAID | 550737600 | 01 | WV | COMMERICAL INSURANCE | OTHER |