Healthcare Provider Details

I. General information

NPI: 1497073290
Provider Name (Legal Business Name): AMANDA MARTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N PORTLAND AVE STE 500
OKLAHOMA CITY OK
73112-2126
US

IV. Provider business mailing address

3000 N GRAND BLVD
OKLAHOMA CITY OK
73107-1818
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-6688
  • Fax:
Mailing address:
  • Phone: 405-632-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29756
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: