Provider Demographics
NPI:1073608592
Name:ETTINGER, ANDRE (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:ETTINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:675 S ARROYO PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3263
Mailing Address - Country:US
Mailing Address - Phone:626-844-0313
Mailing Address - Fax:626-844-0399
Practice Address - Street 1:675 S ARROYO PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3263
Practice Address - Country:US
Practice Address - Phone:626-844-0313
Practice Address - Fax:626-844-0399
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-08-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG73412207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F53681Medicare UPIN