Provider Demographics
NPI:1265469191
Name:DEMETER, ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DEMETER
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:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG PROVIDER RESOURCE GROUP
Practice Address - Street 2:2501 BUENA VISTA
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87125
Practice Address - Country:US
Practice Address - Phone:505-923-5327
Practice Address - Fax:505-923-5305
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000-24207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78078Medicaid
H12130Medicare UPIN
343624202Medicare PIN