MEDICARE: AMANDA DOUEK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	946837151	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	174400000	OTHER	NY	INDEPENDENT

General Provider Information

NPI Number	:	1205291721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA DOUEK

Provider Business Mailing Address
First Line	:	56 BENNETT AVE APT 5L
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-2136
Country	:	US
Telephone Number	:	240-994-8398
Fax Number	:

Provider Business Practice Location Address
First Line	:	56 BENNETT AVE APT 5L
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-2136
Country	:	US
Telephone Number	:	240-994-8398
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2015
Last Update Date	:	12/29/2015

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Directions to “ AMANDA DOUEK ” Practice Location

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