Provider Demographics
NPI:1396710760
Name:OWENS, AMANDA K (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:K
Last Name:OWENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:K
Other - Last Name:ALTAMIRANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1950 GLENN MITCHELL DR
Mailing Address - Street 2:STE 304
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0019
Mailing Address - Country:US
Mailing Address - Phone:757-507-0255
Mailing Address - Fax:757-275-9880
Practice Address - Street 1:1950 GLENN MITCHELL DRIVE
Practice Address - Street 2:STE 304
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456
Practice Address - Country:US
Practice Address - Phone:757-507-0255
Practice Address - Fax:757-275-9880
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236415208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010077486Medicaid
I18573Medicare UPIN
005586S33Medicare ID - Type Unspecified