Provider Demographics
NPI:1821077132
Name:MARSHALL, AMANDA D (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:D
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:D
Other - Last Name:MARSHALL-RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:ID# 2163
Mailing Address - Street 2:PO BOX 659506
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78265-9506
Mailing Address - Country:US
Mailing Address - Phone:210-878-4116
Mailing Address - Fax:210-878-4113
Practice Address - Street 1:18626 HARDY OAK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4210
Practice Address - Country:US
Practice Address - Phone:210-878-4116
Practice Address - Fax:210-878-4113
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113947207X00000X
CODR.0056356207X00000X
TXM4325207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX375169Medicare PIN
TX183607403Medicaid