Provider Demographics
NPI:1255425278
Name:SANTRA, NITYANANDA (MD)
Entity type:Individual
Prefix:DR
First Name:NITYANANDA
Middle Name:
Last Name:SANTRA
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:CENTRAL WV MEDCORP, INC.
Mailing Address - Street 2:P.O. BOX 2630
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-2630
Mailing Address - Country:US
Mailing Address - Phone:304-637-3799
Mailing Address - Fax:304-637-3369
Practice Address - Street 1:911 GORMAN AVENUE
Practice Address - Street 2:SUITE 203
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3154
Practice Address - Country:US
Practice Address - Phone:304-636-5229
Practice Address - Fax:304-636-1015
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09853208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV09853OtherHEALTH PLAN PROVIDER #
WV0127743000Medicaid
WV0382203Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
WV0382202Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
WVWV09853OtherHEALTH PLAN PROVIDER #
WV0382204Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
WVP00073337Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER
WVC34941Medicare UPIN
WV0127743000Medicaid