Provider Demographics
NPI:1366550279
Name:LAO, DOMINADOR YTI (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINADOR
Middle Name:YTI
Last Name:LAO
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 1274
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874-1274
Mailing Address - Country:US
Mailing Address - Phone:304-732-9045
Mailing Address - Fax:304-732-9055
Practice Address - Street 1:RT 10 APPALACHAIN HWY. EAST PINEVILLE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874-1274
Practice Address - Country:US
Practice Address - Phone:304-732-9045
Practice Address - Fax:304-732-9055
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12700207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1220372OtherCHA HEALTH
WV001720313OtherBLUE CROSS/BLUE SHIELD
WV0128304001Medicaid
WV0128304001Medicaid
WV001720313OtherBLUE CROSS/BLUE SHIELD