Provider Demographics
NPI:1477554574
Name:STALLO, PAMELA S (MD)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:S
Last Name:STALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:63 CORPORATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-7841
Mailing Address - Country:US
Mailing Address - Phone:304-691-8870
Mailing Address - Fax:304-691-1665
Practice Address - Street 1:63 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-7841
Practice Address - Country:US
Practice Address - Phone:304-691-8870
Practice Address - Fax:304-691-1665
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV169842080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0107899000Medicaid
F34984Medicare UPIN