Provider Demographics
NPI:1740840008
Name:HARGROVE, AMANDA KATHLEEN (OD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHLEEN
Last Name:HARGROVE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 BLATTNER DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6380
Mailing Address - Country:US
Mailing Address - Phone:573-579-4809
Mailing Address - Fax:
Practice Address - Street 1:2430 S I 35 E STE 156
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-4989
Practice Address - Country:US
Practice Address - Phone:940-484-5587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021297152W00000X
TX9842TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist