Provider Demographics
NPI:1962663187
Name:DVORSCAK, AMANDA JAYNE (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JAYNE
Last Name:DVORSCAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6 WELLNESS WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2156
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:6 WELLNESS WAY STE 102
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2156
Practice Address - Country:US
Practice Address - Phone:518-713-2099
Practice Address - Fax:518-783-7506
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY260494208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03353862Medicaid