Healthcare Provider Details

I. General information

NPI: 1275775520
Provider Name (Legal Business Name): AMANDA DAISY HEARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STONY BROOK MEDICINE DEPT OF EMERG MEDICINE HSC, LEVEL 4, RM 080
STONY BROOK NY
11794-8350
US

IV. Provider business mailing address

STONY BROOK MEDICINE DEPT OF EMERG MEDICINE HSC, LEVEL 4, RM 080
STONY BROOK NY
11794-8350
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2478
  • Fax: 631-444-6031
Mailing address:
  • Phone: 631-444-2478
  • Fax: 631-444-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number264450
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: