Provider Demographics
NPI:1962474064
Name:PHILLIPS, AMANDA RUTH (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:RUTH
Last Name:PHILLIPS
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 1:2390 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4205
Mailing Address - Country:US
Mailing Address - Phone:337-261-6010
Mailing Address - Fax:337-261-6153
Practice Address - Street 1:2390 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4205
Practice Address - Country:US
Practice Address - Phone:337-261-6010
Practice Address - Fax:337-261-6153
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025853207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1042811Medicaid
LA1042811Medicaid