Basic Information
| Provider Information | |||||||||
| NPI: | 1457974396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAMTORA | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | FAMILY MEDICINE CENTER | ||||||||
| Address2: | 40 MEDICAL PARK SUITE 401 | ||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042433880 | ||||||||
| FaxNumber: | 3042433895 | ||||||||
| Practice Location | |||||||||
| Address1: | FAMILY MEDICINE CENTER | ||||||||
| Address2: | 40 MEDICAL PARK SUITE 401 | ||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042433880 | ||||||||
| FaxNumber: | 3042433895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2020 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.