Provider Demographics
NPI:1215155197
Name:BLAIR, AMANDA BOCK (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:BOCK
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-3901
Practice Address - Country:US
Practice Address - Phone:336-716-4085
Practice Address - Fax:336-716-3010
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN61812080P0207X
WA606128872080P0207X
NC2022-022072080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218189302OtherCSHCN
TX218189301Medicaid
TXTXB112924Medicare PIN