Provider Demographics
NPI:1689794083
Name:D'AMICO, ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:D'AMICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 UPLAND TRL
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-9201
Mailing Address - Country:US
Mailing Address - Phone:406-207-7582
Mailing Address - Fax:
Practice Address - Street 1:3205 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8536
Practice Address - Country:US
Practice Address - Phone:406-721-4906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT115952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT011001606Medicare PIN