Provider Demographics
NPI:1801815733
Name:MEDICAL ASSOCIATES OF GLEN DANIEL
Entity Type:Organization
Organization Name:MEDICAL ASSOCIATES OF GLEN DANIEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:JORGE
Authorized Official - Last Name:GORDINHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-254-9022
Mailing Address - Street 1:310 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2653
Mailing Address - Country:US
Mailing Address - Phone:304-254-9022
Mailing Address - Fax:304-254-9024
Practice Address - Street 1:109 BOLT ROAD
Practice Address - Street 2:
Practice Address - City:GLEN DANIEL
Practice Address - State:WV
Practice Address - Zip Code:25844
Practice Address - Country:US
Practice Address - Phone:304-934-5125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPENDING261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0072202000Medicaid
WV0072202000Medicaid