Healthcare Provider Details

I. General information

NPI: 1790075596
Provider Name (Legal Business Name): AMANDA JEAN PETTIBONE-POND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S LIBERTY DR
BLOOMINGTON IN
47403-5167
US

IV. Provider business mailing address

1520 S LIBERTY DR
BLOOMINGTON IN
47403-5167
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4500
  • Fax: 812-676-4501
Mailing address:
  • Phone: 812-353-3087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01076608A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: