Healthcare Provider Details

I. General information

NPI: 1467907006
Provider Name (Legal Business Name): AMANDA GOSTIGIAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER STREET BOX 43
SPRINGFIELD IL
62769-4968
US

IV. Provider business mailing address

800 E CARPENTER STREET BOX 43
SPRINGFIELD IL
62769-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-814-5178
  • Fax: 217-757-6458
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125081875
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: