Provider Demographics
NPI:1891989539
Name:DUTKIEWICZ, AMANDA KATHRINE WILLEMS (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:KATHRINE WILLEMS
Last Name:DUTKIEWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KATHRINE
Other - Last Name:WILLEMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:5TH FL
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-7275
Practice Address - Fax:574-647-3696
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063419A208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200886800Medicaid
IN200886800Medicaid