Provider Demographics
NPI:1790075596
Name:PETTIBONE-POND, AMANDA JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:JEAN
Last Name:PETTIBONE-POND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1520 S LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5167
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:
Practice Address - Street 1:1520 S LIBERTY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5167
Practice Address - Country:US
Practice Address - Phone:812-676-4500
Practice Address - Fax:812-676-4501
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076608A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology