Provider Demographics
NPI:1730428632
Name:HALADIK, AMANDA VENETTIS (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:VENETTIS
Last Name:HALADIK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KATHLEEN
Other - Last Name:VENETTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:130 TOWN CENTER DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8265
Mailing Address - Fax:248-585-8266
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-1007
Practice Address - Fax:248-964-6065
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101020303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program