Healthcare Provider Details

I. General information

NPI: 1437530169
Provider Name (Legal Business Name): AMANDA J WATLINGTON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW STREET EMERGENCY RESIDENCY PROGRAM
MARIETTA OH
45750
US

IV. Provider business mailing address

401 MATTHEW STREET EMERGENCY RESIDENCY PROGRAM
MARIETTA OH
45750
US

V. Phone/Fax

Practice location:
  • Phone: 740-568-5669
  • Fax:
Mailing address:
  • Phone: 740-568-5669
  • Fax:

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 Number34013206
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: