1124316195 NPI number — AMANDA L DENZIK DPM

Table of content: AMANDA L DENZIK DPM (NPI 1124316195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124316195 NPI number — AMANDA L DENZIK DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENZIK
Provider First Name:
AMANDA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAY
Provider Other First Name:
AMANDA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124316195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4612 OUTER LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40219-3971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-804-4811
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4612 OUTER LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40219-3971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-968-2233
Provider Business Practice Location Address Fax Number:
502-968-2283
Provider Enumeration Date:
07/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  07001180A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 243983 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50071771 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100307170 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201243030 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01370863 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000880754 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com