Basic Information
| Provider Information | |||||||||
| NPI: | 1093783060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CESTARIC | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | AUGUST | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 609 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261430609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042753301 | ||||||||
| FaxNumber: | 3042754798 | ||||||||
| Practice Location | |||||||||
| Address1: | 512A SOUTH CHURCH STREET | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252711616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043721033 | ||||||||
| FaxNumber: | 3043730223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.015445 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1905 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1842022000 | 05 | WV | MEDICAID | P00403709 | 01 | RAILROAD MEDICARE | OTHER | 3810010399 | 05 | WV | MEDICAID | 2601590 | 05 | OH | MEDICAID |