Provider Demographics
NPI:1104069806
Name:MCCOY, AMANDA (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 CHANDLER ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-2915
Mailing Address - Country:US
Mailing Address - Phone:508-752-4511
Mailing Address - Fax:508-797-4729
Practice Address - Street 1:421 CHANDLER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602-2915
Practice Address - Country:US
Practice Address - Phone:508-752-4511
Practice Address - Fax:508-797-4729
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
62865390200000X
MA251174208000000X
NY263478208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program