Provider Demographics
NPI:1578944096
Name:DAVALA, AMANDA MILLER (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MILLER
Last Name:DAVALA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KATHERINE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:743 N 20TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2003
Mailing Address - Country:US
Mailing Address - Phone:215-622-4509
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016473390200000X
PAOS019791207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program