Provider Demographics
NPI:1871158030
Name:MIRMANESH, AMANDA (DO)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MIRMANESH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 DELSEA DR N
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1444
Mailing Address - Country:US
Mailing Address - Phone:856-507-2783
Mailing Address - Fax:
Practice Address - Street 1:2950 COLLEGE DR STE 2D
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6933
Practice Address - Country:US
Practice Address - Phone:856-641-6313
Practice Address - Fax:856-497-5350
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11854600207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty