Provider Demographics
NPI:1447423397
Name:ANDRE, LA VERGNE (DPM)
Entity Type:Individual
Prefix:MRS
First Name:LA VERGNE
Middle Name:
Last Name:ANDRE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14202 LAKE RUN CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4861
Mailing Address - Country:US
Mailing Address - Phone:301-323-5652
Mailing Address - Fax:410-740-2412
Practice Address - Street 1:14202 LAKE RUN CT
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4861
Practice Address - Country:US
Practice Address - Phone:301-323-5652
Practice Address - Fax:410-740-2412
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1101213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT315Medicare PIN
MD4804740002Medicare NSC
DC168752Medicare PIN