Provider Demographics
NPI:1790782753
Name:ENDICOTT, JAMES WILLIAM (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:WILLIAM
Last Name:ENDICOTT
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:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:WV
Mailing Address - Zip Code:25674-0430
Mailing Address - Country:US
Mailing Address - Phone:304-393-4303
Mailing Address - Fax:304-393-3254
Practice Address - Street 1:108 MINGO ST
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25674-0430
Practice Address - Country:US
Practice Address - Phone:304-393-4303
Practice Address - Fax:304-393-3254
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0051733000Medicaid
A72438Medicare UPIN
WV0051733000Medicaid