Provider Demographics
NPI:1134133762
Name:AMALFITANO, ANDREA (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:AMALFITANO
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 1:804 SERVICE RD # A201
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:1600 W GRAND RIVER STE 2
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864
Practice Address - Country:US
Practice Address - Phone:517-349-6560
Practice Address - Fax:517-349-5796
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011076207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134133762Medicaid
MI4891301Medicaid
F44809Medicare UPIN
MIC36092274Medicare PIN