Provider Demographics
NPI:1386657039
Name:CASSIDENTI, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:CASSIDENTI
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 1:43 LAGUNA WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2829
Mailing Address - Country:US
Mailing Address - Phone:949-683-7899
Mailing Address - Fax:661-326-2138
Practice Address - Street 1:1140 W LA VETA AVE STE 560
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4214
Practice Address - Country:US
Practice Address - Phone:714-835-0101
Practice Address - Fax:714-835-1133
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE58956Medicare UPIN