Basic Information
| Provider Information | |||||||||
| NPI: | 1245264928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUNANAN | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1112 | ||||||||
| Address2: | 1322 LOCUST AVE | ||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043660700 | ||||||||
| FaxNumber: | 3043669529 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322 LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043660700 | ||||||||
| FaxNumber: | 3043669529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
| 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 | 2085R0202X | 10937 | WV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000401637 | 01 | WV | MT STATE BC/BS | OTHER | 1245264928 | 01 | WV | OHIO WORKER'S COMP | OTHER | 300041849 | 01 | WV | RR MEDICARE | OTHER | 0121537000 | 05 | WV | MEDICAID | 252745 | 01 | WV | OPTIMUM CHOICE | OTHER | 550486849 0059 | 01 | WV | CIGNA | OTHER | WV10937 | 01 | WV | HEALTH PLAN | OTHER | 0004507104 | 01 | WV | AETNA | OTHER | 485042 | 01 | WV | NATIONAL CAPITAL PPO | OTHER | D49326 | 01 | WV | WV WORKER'S COMP | OTHER |