Basic Information
| Provider Information | |||||||||
| NPI: | 1730428632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALADIK | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | VENETTIS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | VENETTIS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 TOWN CENTER DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485858265 | ||||||||
| FaxNumber: | 2485858266 | ||||||||
| Practice Location | |||||||||
| Address1: | 44201 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480851117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489641007 | ||||||||
| FaxNumber: | 2489646065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2013 | ||||||||
| LastUpdateDate: | 03/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 5101020303 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.