Provider Demographics
NPI:1871591818
Name:CHUA, DOMINGO T (MD)
Entity type:Individual
Prefix:
First Name:DOMINGO
Middle Name:T
Last Name:CHUA
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 2237
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-2237
Mailing Address - Country:US
Mailing Address - Phone:304-636-6065
Mailing Address - Fax:
Practice Address - Street 1:1092 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3671
Practice Address - Country:US
Practice Address - Phone:304-636-6065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2010-01-13
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
WV09561208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0130598000Medicaid
WV0377291Medicare PIN
WVD49189Medicare UPIN