Provider Demographics
NPI:1922007186
Name:PATHAK, KISHOR S (MD)
Entity Type:Individual
Prefix:DR
First Name:KISHOR
Middle Name:S
Last Name:PATHAK
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 1:200 NEW HOPE RD
Mailing Address - Street 2:PO BOX 1559
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2155
Mailing Address - Country:US
Mailing Address - Phone:304-487-1076
Mailing Address - Fax:304-425-9499
Practice Address - Street 1:200 NEW HOPE RD
Practice Address - Street 2:QUAIL VALLEY MEDICAL CENTER NO 7
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2155
Practice Address - Country:US
Practice Address - Phone:304-487-1076
Practice Address - Fax:304-425-9499
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV110612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0120861000Medicaid
D49257Medicare UPIN
WV0120861000Medicaid