Provider Demographics
NPI:1124316195
Name:DENZIK, AMANDA L (DPM)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:DENZIK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:4612 OUTER LOOP
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3971
Mailing Address - Country:US
Mailing Address - Phone:502-804-4811
Mailing Address - Fax:
Practice Address - Street 1:4612 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3971
Practice Address - Country:US
Practice Address - Phone:502-968-2233
Practice Address - Fax:502-968-2283
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001180A213ES0103X
KY243983213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50071771OtherPASSPORT HEALTH PLAN
KY7100307170Medicaid
IN201243030Medicaid
INP01370863OtherRAILROAD MEDICARE
KY000000880754OtherANTHEM
KYK151720Medicare PIN
IN201243030Medicaid