Provider Demographics
NPI:1174947220
Name:ROBERTS, AMANDA MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MICHELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2644 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-4902
Practice Address - Country:US
Practice Address - Phone:405-254-5565
Practice Address - Fax:405-254-5569
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101259069207N00000X, 208D00000X
AZ65007207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice