Provider Demographics
NPI:1194036293
Name:JAN, AMANDA IRENE (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:IRENE
Last Name:JAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:IRENE JAN
Other - Last Name:FROST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2121 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2303
Mailing Address - Country:US
Mailing Address - Phone:310-829-8177
Mailing Address - Fax:
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-829-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1261692080N0001X
390200000X
CAA1261692080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program