Provider Demographics
NPI:1699034454
Name:ANTONIO, AMANDA CUNNINGHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:CUNNINGHAM
Last Name:ANTONIO
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3470
Mailing Address - Fax:
Practice Address - Street 1:1810 ELDRON BLVD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909
Practice Address - Country:US
Practice Address - Phone:321-312-3470
Practice Address - Fax:321-409-6813
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME142668207Q00000X
SCMD36298208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP02413866OtherRRMR
FLLX216OtherMEDICARE