Provider Demographics
NPI:1134128358
Name:IMBING, FAUSTO (MD)
Entity Type:Individual
Prefix:MR
First Name:FAUSTO
Middle Name:
Last Name:IMBING
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 1:81 BALL PARK RD
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-1701
Mailing Address - Country:US
Mailing Address - Phone:606-574-8366
Mailing Address - Fax:606-574-8011
Practice Address - Street 1:306 STANAFORD RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3142
Practice Address - Country:US
Practice Address - Phone:606-574-8366
Practice Address - Fax:606-574-8013
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19228207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64072531Medicaid
KY6594529700Medicaid
WV0104280000Medicaid
KY64072531Medicaid
WV0104280000Medicaid