Basic Information
| Provider Information | |||||||||
| NPI: | 1053442541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANTONIO TAMARA MD LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 489 | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247010489 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254013402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042641212 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 06/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | TAMARA | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3042641212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 3810009862 | 05 | WV | MEDICAID | DG3243 | 01 | RAILROAD MEDICARE | OTHER |