Provider Demographics
NPI:1386633907
Name:EGLEVSKY, ANDRE (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:EGLEVSKY
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 1:2201 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3378
Mailing Address - Country:US
Mailing Address - Phone:540-371-5333
Mailing Address - Fax:540-372-6978
Practice Address - Street 1:2201 CHARLES ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3378
Practice Address - Country:US
Practice Address - Phone:540-371-5333
Practice Address - Fax:540-372-6978
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028315207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6460305Medicaid
B07696Medicare UPIN