Provider Demographics
NPI:1134127004
Name:ANDREATTA, MARIO J (OD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:ANDREATTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 JACKIE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6610
Mailing Address - Country:US
Mailing Address - Phone:505-892-8411
Mailing Address - Fax:505-891-5497
Practice Address - Street 1:4025 JACKIE RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6610
Practice Address - Country:US
Practice Address - Phone:505-892-8411
Practice Address - Fax:505-891-5497
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2438152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ006007OtherAHCCCS
NM0438OtherEYE MED ID
NMNMOP2438OtherLICENSE #
NM152W0000XMedicaid
85-0407195OtherGROUP EIN
NMNMOP2438OtherLICENSE #
0772190001Medicare NSC
85-0407195OtherGROUP EIN