Provider Demographics
NPI:1033560354
Name:MEDENBACH, ANDREW JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JAMES
Last Name:MEDENBACH
Suffix:
Gender:M
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:BLDG 50 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:AGANA HEIGHTS
Mailing Address - State:GU
Mailing Address - Zip Code:96910
Mailing Address - Country:US
Mailing Address - Phone:671-344-9340
Mailing Address - Fax:
Practice Address - Street 1:BLDG 50, FARENHOLT AVE
Practice Address - Street 2:NAVAL HOSPITAL GUAM
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-344-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
GUDO-P-2023-002207P00000X
NE1711207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicare UPIN