Provider Demographics
NPI:1780079830
Name:AMAL, TOMMY MIKAL
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:MIKAL
Last Name:AMAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 S MAIN ST
Mailing Address - Street 2:303-C
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6634
Mailing Address - Country:US
Mailing Address - Phone:773-818-9052
Mailing Address - Fax:
Practice Address - Street 1:1999 S MAIN ST
Practice Address - Street 2:303-C
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6634
Practice Address - Country:US
Practice Address - Phone:773-818-9052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA343900000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver