Basic Information
Provider Information | |||||||||
NPI: | 1598786253 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAJESTRO | ||||||||
FirstName: | TONY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 415 MORRIS STREET | ||||||||
Address2: | STE 104 | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 25301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043431399 | ||||||||
FaxNumber: | 3043457824 | ||||||||
Practice Location | |||||||||
Address1: | 415 MORRIS STREET | ||||||||
Address2: | STE 104 | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 25301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043431399 | ||||||||
FaxNumber: | 3043457824 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2006 | ||||||||
LastUpdateDate: | 05/01/2008 | ||||||||
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 | 207X00000X | 08956 | WV | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0098852000 | 05 | WV |   | MEDICAID | 0660720001 | 01 |   | CIGNA GOVERNMENT SERVICES | OTHER | 2138102 | 01 | WV | UNITED HCARE | OTHER | 001717974 | 01 | WV | BCBS | OTHER |