Provider Demographics
NPI:1225357122
Name:CARBERRY, ANDREA R (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:CARBERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2883
Mailing Address - Country:US
Mailing Address - Phone:920-969-7906
Mailing Address - Fax:920-969-7979
Practice Address - Street 1:130 2ND ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-969-7906
Practice Address - Fax:920-969-7979
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57157208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1225357122Medicaid