Provider Demographics
NPI:1366451700
Name:ERNESTO T.YUTIAMCO,M.D.,P.C.
Entity Type:Organization
Organization Name:ERNESTO T.YUTIAMCO,M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:T
Authorized Official - Last Name:YUTIAMCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-369-0221
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-0428
Mailing Address - Country:US
Mailing Address - Phone:304-369-0221
Mailing Address - Fax:304-369-0222
Practice Address - Street 1:483 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1223
Practice Address - Country:US
Practice Address - Phone:304-369-0221
Practice Address - Fax:304-369-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13306208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049816000Medicaid
WVYU0519011Medicare ID - Type Unspecified
WVD49098Medicare UPIN