Provider Demographics
NPI:1710265715
Name:GODFREY, AMANDA M T (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M T
Last Name:GODFREY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:TAMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:35 S MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 S MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1122
Practice Address - Country:US
Practice Address - Phone:570-474-5978
Practice Address - Fax:570-474-5485
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2650207Q00000X
390200000X
PAOS016918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program