Provider Demographics
NPI:1699937862
Name:DIDOLKAR, AMANDA JACQUELYN (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JACQUELYN
Last Name:DIDOLKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JACQUELYN
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PATIENT ACCOUNTING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:4022 POSTAL WAY STE C
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3537
Practice Address - Country:US
Practice Address - Phone:843-903-4111
Practice Address - Fax:843-903-4242
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC84825208000000X
IN01069849208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC848257Medicaid
TNQ027544Medicaid