Provider Demographics
NPI:1134500143
Name:KOIVUNIEMI, ANDREW SANFORD (MD/PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:SANFORD
Last Name:KOIVUNIEMI
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3001 S CREASY LN STE 100A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5206
Practice Address - Country:US
Practice Address - Phone:765-701-6451
Practice Address - Fax:765-420-5801
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01088594A207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11018180AOtherPROFESSIONAL LICENSING AGENCY