Provider Demographics
NPI:1124280680
Name:GRIFFIN, AMANDA DIANE (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DIANE
Last Name:GRIFFIN
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 1:110 W 7TH ST STE 2520
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-1104
Mailing Address - Country:US
Mailing Address - Phone:918-579-3826
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:1301 NE 13TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361
Practice Address - Country:US
Practice Address - Phone:918-824-6479
Practice Address - Fax:918-550-6742
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45631208000000X
TXN9560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280022902Medicaid
TX280022904Medicaid
TX280022903Medicaid
OK200339720 AMedicaid
TX280022901Medicaid
NM78286051Medicaid
TX280022903Medicaid
TXTXB135948Medicare PIN