Provider Demographics
NPI:1053795922
Name:MAMMANO, AMANDA (OD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MAMMANO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GERROUGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1200 W GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3323
Mailing Address - Country:US
Mailing Address - Phone:215-276-6173
Mailing Address - Fax:215-276-1329
Practice Address - Street 1:110 MERCER ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3865
Practice Address - Country:US
Practice Address - Phone:212-431-4440
Practice Address - Fax:212-431-4404
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003061152W00000X
NYTUV008412152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA13584891OtherCAQH NUMBER