Healthcare Provider Details

I. General information

NPI: 1255575130
Provider Name (Legal Business Name): AMY ELIZABETH IWAMAYE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

513 E MURDOCH RD
PHILADELPHIA PA
19119-1027
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-5734
  • Fax:
Mailing address:
  • Phone: 732-241-7278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD445484
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMT194633
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: