Provider Demographics
NPI:1396843231
Name:BURGO-BLACK, ANDREA LUCILE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:LUCILE
Last Name:BURGO-BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:LUCILE
Other - Last Name:BURGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20 KENTER PL
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-2412
Mailing Address - Country:US
Mailing Address - Phone:203-389-6335
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:VACT HEALTHCARE SYSTEM
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:203-937-3403
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025451207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTVADOOOMedicare UPIN