Provider Demographics
NPI:1518055508
Name:IVY, AMANDA MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:IVY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:IVY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1340 WONDER WORLD DR
Mailing Address - Street 2:STE 4301
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7598
Mailing Address - Country:US
Mailing Address - Phone:512-353-6400
Mailing Address - Fax:
Practice Address - Street 1:1340 WONDER WORLD DR
Practice Address - Street 2:STE 4301
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7598
Practice Address - Country:US
Practice Address - Phone:512-353-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9880207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine