Provider Demographics
NPI:1811944259
Name:DORNFELD, AMANDA MARIE (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:DORNFELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:PENCEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3118 N NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3169
Mailing Address - Country:US
Mailing Address - Phone:812-308-4594
Mailing Address - Fax:812-302-2130
Practice Address - Street 1:3118 N NATIONAL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3169
Practice Address - Country:US
Practice Address - Phone:812-308-4594
Practice Address - Fax:812-302-2130
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059524A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01059524AOtherMEDICAL LICENSE
IN1811944259Medicaid
P00347446OtherRAILROAD MEDICARE
IN01059524AOtherMEDICAL LICENSE
I23714Medicare UPIN
IN200501180Medicaid