Provider Demographics
NPI:1265420244
Name:MAIDENBERG, AMY M (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:MAIDENBERG
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:PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-0618
Mailing Address - Country:US
Mailing Address - Phone:510-433-1040
Mailing Address - Fax:510-864-1934
Practice Address - Street 1:4329 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-4715
Practice Address - Country:US
Practice Address - Phone:510-418-9331
Practice Address - Fax:888-844-4383
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040212208000000X
CAA98623208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8373482Medicaid
WAAB40138Medicare ID - Type Unspecified
WAH97047Medicare UPIN