Provider Demographics
NPI:1982164810
Name:DORN, AMANDA DAVIS (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAVIS
Last Name:DORN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 PENSACOLA ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2118
Mailing Address - Country:US
Mailing Address - Phone:808-432-2000
Mailing Address - Fax:
Practice Address - Street 1:235 E PRINCETON ST STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5555
Practice Address - Country:US
Practice Address - Phone:407-303-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-2293207Q00000X
SC390200000X
FLUO8854390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine