Provider Demographics
NPI:1619960176
Name:VASILAKIS-DONZELLA, AMY ANNE (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANNE
Last Name:VASILAKIS-DONZELLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ANNE
Other - Last Name:VASILAKIS-DONZELLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1315 MT. DECHANTAL ROAD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6392
Mailing Address - Country:US
Mailing Address - Phone:304-243-7117
Mailing Address - Fax:
Practice Address - Street 1:1315 MT. DECHANTAL ROAD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6392
Practice Address - Country:US
Practice Address - Phone:304-243-7117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2410064Medicaid
1899OtherHEALTH PLAN OF UPPER OH V
OH21502391100OtherOHIO BWC
001718181OtherMOUNTAIN STATE BCBS
WV55035705700OtherWV COMPENSATION
WV1809463000Medicaid
1899OtherHEALTH PLAN OF UPPER OH V
P00019112Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WV1809463000Medicaid