Provider Demographics
NPI:1629061932
Name:HARDMAN, AMY WINTERBOTHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:WINTERBOTHAM
Last Name:HARDMAN
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 1:2121 PARK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3811
Mailing Address - Country:US
Mailing Address - Phone:904-387-6200
Mailing Address - Fax:904-387-0261
Practice Address - Street 1:2121 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3811
Practice Address - Country:US
Practice Address - Phone:904-387-6200
Practice Address - Fax:904-387-0261
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 764182080A0000X
FLME76418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259018200Medicaid
FL259018200Medicaid