Provider Demographics
NPI:1093808172
Name:CAMOMOT, WIGBERTO C
Entity Type:Individual
Prefix:
First Name:WIGBERTO
Middle Name:C
Last Name:CAMOMOT
Suffix:
Gender:M
Credentials:
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 329
Mailing Address - Street 2:
Mailing Address - City:RED JACKET
Mailing Address - State:WV
Mailing Address - Zip Code:25692-0329
Mailing Address - Country:US
Mailing Address - Phone:304-426-6428
Mailing Address - Fax:304-426-8413
Practice Address - Street 1:329 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RED JACKET
Practice Address - State:WV
Practice Address - Zip Code:25692-0329
Practice Address - Country:US
Practice Address - Phone:304-426-6428
Practice Address - Fax:304-426-8413
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13624208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0050600000Medicaid
WV0050600000Medicaid
0541461Medicare PIN