Provider Demographics
NPI:1699774315
Name:ENDICOTT, MICHELLE LEIGH (DO)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEIGH
Last Name:ENDICOTT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 KANAWHA AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1207
Mailing Address - Country:US
Mailing Address - Phone:304-768-4567
Mailing Address - Fax:304-768-2277
Practice Address - Street 1:4815 KANAWHA AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1207
Practice Address - Country:US
Practice Address - Phone:304-768-4567
Practice Address - Fax:304-768-2277
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2097207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002529Medicaid
WV3810002529Medicaid
WVMI9355431Medicare PIN
WV202162808OtherEIN #