Provider Demographics
NPI:1417579186
Name:CIMINO, AMANDA PROVOST (DO)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:PROVOST
Last Name:CIMINO
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1922
Mailing Address - Fax:
Practice Address - Street 1:17000 HUBBARD DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4258
Practice Address - Country:US
Practice Address - Phone:313-982-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315216509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine