Provider Demographics
NPI:1275606568
Name:PROSSER, ANDREA KARIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:KARIN
Last Name:PROSSER
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 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:6104 OLD BRANCH AVENUE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2518
Practice Address - Country:US
Practice Address - Phone:301-702-6100
Practice Address - Fax:301-702-6366
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059149208000000X
MDD59149152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H82149Medicare UPIN
011398M92Medicare ID - Type Unspecified