Provider Demographics
NPI:1750583399
Name:PONG, AMANDA W (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:W
Last Name:PONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 FOREST ST
Mailing Address - Street 2:APT 1421
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901
Mailing Address - Country:US
Mailing Address - Phone:619-322-2577
Mailing Address - Fax:
Practice Address - Street 1:50 FOREST ST
Practice Address - Street 2:APT 1421
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901
Practice Address - Country:US
Practice Address - Phone:619-322-2577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2496592084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology