Provider Demographics
NPI:1750677852
Name:COBB, AMANDA JANETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:JANETTE
Last Name:COBB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:27900 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7009
Mailing Address - Country:US
Mailing Address - Phone:251-621-1211
Mailing Address - Fax:251-621-9052
Practice Address - Street 1:27900 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7009
Practice Address - Country:US
Practice Address - Phone:251-621-1211
Practice Address - Fax:251-621-9052
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C55152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS-C55OtherALABAMA BOARD OF OPTOMETRY