Provider Demographics
NPI:1619082112
Name:ALTDORFER, GABOR I (MD)
Entity type:Individual
Prefix:
First Name:GABOR
Middle Name:
Last Name:ALTDORFER
Suffix:I
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 718
Mailing Address - Street 2:MEDICAL OFFICE BLDG. B., SUITE 180
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26102-0718
Mailing Address - Country:US
Mailing Address - Phone:740-274-0790
Mailing Address - Fax:304-424-2717
Practice Address - Street 1:705 GARFIELD AVE
Practice Address - Street 2:MEDICAL OFFICE BLDG. B., SUITE 180
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5444
Practice Address - Country:US
Practice Address - Phone:740-274-0790
Practice Address - Fax:304-424-2717
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV232942085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7390611Medicare PIN