Provider Demographics
NPI:1093778912
Name:AMIN, MAYANK S (MD)
Entity Type:Individual
Prefix:
First Name:MAYANK
Middle Name:S
Last Name:AMIN
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 213
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-0213
Mailing Address - Country:US
Mailing Address - Phone:304-324-2715
Mailing Address - Fax:304-324-2774
Practice Address - Street 1:512 CHERRY ST
Practice Address - Street 2:BUILDING I
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3341
Practice Address - Country:US
Practice Address - Phone:304-324-2715
Practice Address - Fax:304-324-2774
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0082212000Medicaid
WVG84197Medicare UPIN