Provider Demographics
NPI:1780940858
Name:FANT, AMANDA R (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:FANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:K
Other - Last Name:ROYSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4895 OLENTANGY RIVER RD. STE 250
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1184
Mailing Address - Country:US
Mailing Address - Phone:614-267-8371
Mailing Address - Fax:614-262-0005
Practice Address - Street 1:4895 OLENTANGY RIVER RD STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1184
Practice Address - Country:US
Practice Address - Phone:614-267-8371
Practice Address - Fax:614-262-0005
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35130599207R00000X
TN52562208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214594Medicaid