Provider Demographics
NPI:1134383813
Name:MOFOR-ETA, FRI (MD)
Entity type:Individual
Prefix:DR
First Name:FRI
Middle Name:
Last Name:MOFOR-ETA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-1528
Mailing Address - Country:US
Mailing Address - Phone:304-857-6503
Mailing Address - Fax:
Practice Address - Street 1:2416 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1528
Practice Address - Country:US
Practice Address - Phone:304-857-6503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092844207V00000X
KYTP444207V00000X
WV26103207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty