Provider Demographics
NPI:1851377576
Name:LAIRD, AMANDA M (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:M
Last Name:LAIRD
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 1:320 E 58TH ST
Mailing Address - Street 2:APT 3H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2404
Practice Address - Country:US
Practice Address - Phone:718-920-4059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-00135208600000X
NC0200135208600000X
MI4301096481208600000X
TXP1559208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901563Medicaid
MII33581Medicare UPIN
NC2041436BMedicare ID - Type UnspecifiedCTS MEDICARE NUMBER
2041436Medicare PIN
NC2041436AMedicare ID - Type UnspecifiedCSG MEDICARE NUMBER
NC5901563Medicaid
NCI33581Medicare UPIN