Provider Demographics
NPI:1942219365
Name:YUTIAMCO, ERNESTO T (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:T
Last Name:YUTIAMCO
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 428
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-0428
Mailing Address - Country:US
Mailing Address - Phone:304-369-0221
Mailing Address - Fax:304-369-0222
Practice Address - Street 1:483 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1223
Practice Address - Country:US
Practice Address - Phone:304-369-0221
Practice Address - Fax:304-369-0222
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13306208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049816000Medicaid
WVYU0519011Medicare ID - Type Unspecified
WV0049816000Medicaid