Provider Demographics
NPI:1972598944
Name:AMIGO, ANTHONY M (MD)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:M
Last Name:AMIGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 MOREAU ST
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-2956
Mailing Address - Country:US
Mailing Address - Phone:318-253-5647
Mailing Address - Fax:318-253-5876
Practice Address - Street 1:338 MOREAU ST
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2956
Practice Address - Country:US
Practice Address - Phone:318-253-5647
Practice Address - Fax:318-253-5876
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11268R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1664839Medicaid
LA5Y016Medicare ID - Type Unspecified
LAF85627Medicare UPIN
LA1200070002Medicare ID - Type Unspecified