Provider Demographics
NPI:1124280680
Name:GRIFFIN, AMANDA DIANE (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DIANE
Last Name:GRIFFIN
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 1:1400 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-414-9800
Mailing Address - Fax:806-354-5689
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-414-9800
Practice Address - Fax:806-354-5689
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN9560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78286051Medicaid
TX280022902Medicaid
TX280022904Medicaid
TX280022903Medicaid
OK200339720 AMedicaid
TX280022901Medicaid
TX280022903Medicaid
TXTXB135948Medicare PIN