Provider Demographics
NPI:1669486668
Name:AMIEWALAN, ANTHONY ORIA I (MD FACOG)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:ORIA
Last Name:AMIEWALAN
Suffix:I
Gender:M
Credentials:MD FACOG
Other - Prefix:DR
Other - First Name:ANTHONY
Other - Middle Name:ORIA
Other - Last Name:AMIE
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1750 EAST LAKE SHORE DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521
Mailing Address - Country:US
Mailing Address - Phone:217-422-0560
Mailing Address - Fax:217-422-0872
Practice Address - Street 1:1750 EAST LAKE SHORE DR
Practice Address - Street 2:SUITE 320
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-422-0560
Practice Address - Fax:217-422-0872
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112019207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112019Medicaid
B65621Medicare ID - Type Unspecified
IL036112019Medicaid