Provider Demographics
NPI:1457640476
Name:LOUCKS, AMANDA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:LOUCKS
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 1:1215 LEE ST
Mailing Address - Street 2:BOX 800729
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-924-0211
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:BOX 800729
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-924-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101256130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine