Provider Demographics
NPI:1487619813
Name:SAKKAL, AMAL FUSTOK (MD)
Entity type:Individual
Prefix:
First Name:AMAL
Middle Name:FUSTOK
Last Name:SAKKAL
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 1:331 LAIDLEY ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1619
Mailing Address - Country:US
Mailing Address - Phone:304-346-1410
Mailing Address - Fax:304-344-0188
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:SUITE 406
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-346-1410
Practice Address - Fax:304-344-0188
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0080971000Medicaid
SA0838454Medicare PIN
WV0838452Medicare ID - Type Unspecified
WV0080971000Medicaid