Provider Demographics
NPI:1174508998
Name:ANDRES, LJUDEVIT (MD)
Entity Type:Individual
Prefix:DR
First Name:LJUDEVIT
Middle Name:
Last Name:ANDRES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-771-0304
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:811 AINSWORTH DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1687
Practice Address - Country:US
Practice Address - Phone:928-771-5548
Practice Address - Fax:928-771-5549
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32009207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ834722Medicaid
AZA45096Medicare UPIN