Provider Demographics
NPI:1053471045
Name:LALLANDE, ANDRE P (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:P
Last Name:LALLANDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:ANDRE
Other - Middle Name:P
Other - Last Name:LALLANDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:5726 RIDGEMARK PL
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5159
Mailing Address - Country:US
Mailing Address - Phone:909-559-1050
Mailing Address - Fax:
Practice Address - Street 1:5726 RIDGEMARK PL
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5159
Practice Address - Country:US
Practice Address - Phone:909-559-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7021207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0575313OtherCLIA # FOR GROUP
CAZZZ34392ZOtherMEDICARE GROUP ID
CAG60960Medicare UPIN
CAG60960Medicare UPIN
CAZZZ34392ZOtherMEDICARE GROUP ID