Provider Demographics
NPI:1497073290
Name:MARTIN, AMANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MARTIN
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 1:3000 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1818
Mailing Address - Country:US
Mailing Address - Phone:405-632-6688
Mailing Address - Fax:
Practice Address - Street 1:5401 N PORTLAND AVE STE 500
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2126
Practice Address - Country:US
Practice Address - Phone:405-632-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29756208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program