Healthcare Provider Details

I. General information

NPI: 1841405370
Provider Name (Legal Business Name): MARK STEVEN AMONETTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 WOODS WAY
STATE FARM VA
23160-0002
US

IV. Provider business mailing address

3921 FIGHTING CREEK DR
POWHATAN VA
23139-7040
US

V. Phone/Fax

Practice location:
  • Phone: 804-598-4251
  • Fax: 804-403-3495
Mailing address:
  • Phone: 804-598-0626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101041647
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: