Provider Demographics
NPI:1043486145
Name:NAMSUPAK, JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:NAMSUPAK
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 1:401 GUFFEY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4029
Mailing Address - Country:US
Mailing Address - Phone:304-363-2500
Mailing Address - Fax:304-363-0263
Practice Address - Street 1:401 GUFFEY ST
Practice Address - Street 2:JOHN MANCHIN SR. HEALTH CARE CENTER
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4029
Practice Address - Country:US
Practice Address - Phone:304-363-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23919208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016983Medicaid
WV4285421Medicare PIN