Provider Demographics
NPI:1043213655
Name:TAMARA, ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:TAMARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-0489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL DRIVE
Practice Address - Street 2:CITY HOSPITAL
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-3402
Practice Address - Country:US
Practice Address - Phone:304-264-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11343207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
110027353OtherRAILROAD MEDICARE
WV0101794000Medicaid
C35069Medicare UPIN
WV4221771Medicare PIN