Provider Demographics
NPI:1821049339
Name:AMIGO, ISIDRO A (DO)
Entity Type:Individual
Prefix:DR
First Name:ISIDRO
Middle Name:A
Last Name:AMIGO
Suffix:
Gender:M
Credentials:DO
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 42738
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21284-2738
Mailing Address - Country:US
Mailing Address - Phone:844-468-9502
Mailing Address - Fax:317-663-6054
Practice Address - Street 1:8 ROSE ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1678
Practice Address - Country:US
Practice Address - Phone:304-265-0095
Practice Address - Fax:304-265-6215
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002976208600000X
WV1181208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0128645000Medicaid
OH0551675Medicaid
WVWV6330F050Medicare PIN
WV0128645000Medicaid
OH0551675Medicaid