Provider Demographics
NPI:1437295938
Name:DEANDREA, G. A (MD)
Entity Type:Individual
Prefix:
First Name:G.
Middle Name:A
Last Name:DEANDREA
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:PO BOX 748157
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-8157
Mailing Address - Country:US
Mailing Address - Phone:541-789-5250
Mailing Address - Fax:541-789-5538
Practice Address - Street 1:520 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4334
Practice Address - Country:US
Practice Address - Phone:541-789-5710
Practice Address - Fax:541-789-5711
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000267272084N0400X, 2084S0012X
FLME720612084N0400X, 2084S0012X
ORMD1565252084N0400X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E74813Medicare UPIN
000108457Medicare ID - Type Unspecified