Provider Demographics
NPI:1063864569
Name:HARTFORD, ANDREA (DO)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:HARTFORD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6002 WESTGATE BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2572
Mailing Address - Country:US
Mailing Address - Phone:253-761-2244
Mailing Address - Fax:253-761-1040
Practice Address - Street 1:1428 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1437
Practice Address - Country:US
Practice Address - Phone:248-845-4237
Practice Address - Fax:248-693-3683
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101027793207V00000X
WAOP61292581207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2211802Medicaid