Provider Demographics
NPI:1033121652
Name:ANDINO, RAUL RENE (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:RENE
Last Name:ANDINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RAUL
Other - Middle Name:RENE
Other - Last Name:ANDINO-QUINONEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:505 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1266
Mailing Address - Country:US
Mailing Address - Phone:517-748-5500
Mailing Address - Fax:517-780-9286
Practice Address - Street 1:505 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1266
Practice Address - Country:US
Practice Address - Phone:517-748-5500
Practice Address - Fax:517-780-9286
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10941207V00000X
MI4301085215207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200018350AMedicaid
OK200018350AMedicaid