Provider Demographics
NPI:1255794871
Name:AMENDOLA, MAURO (MD)
Entity type:Individual
Prefix:DR
First Name:MAURO
Middle Name:
Last Name:AMENDOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 S HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4610
Mailing Address - Country:US
Mailing Address - Phone:330-720-8413
Mailing Address - Fax:
Practice Address - Street 1:8110 CORDOVA RD STE 111
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0522
Practice Address - Country:US
Practice Address - Phone:901-752-6963
Practice Address - Fax:901-432-0070
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS31446207Q00000X
OH35.138734207Q00000X
390200000X
TN66230207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program