Provider Demographics
NPI:1508139676
Name:ANDREA D. ANDERSON, MD., INC.
Entity Type:Organization
Organization Name:ANDREA D. ANDERSON, MD., INC.
Other - Org Name:PROFESSIONAL WOUND CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:951-493-1992
Mailing Address - Street 1:4190 GREEN RIVER RD
Mailing Address - Street 2:#201
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-1507
Mailing Address - Country:US
Mailing Address - Phone:951-493-1992
Mailing Address - Fax:951-493-1919
Practice Address - Street 1:2815 S MAIN ST
Practice Address - Street 2:#215
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-2531
Practice Address - Country:US
Practice Address - Phone:951-493-1995
Practice Address - Fax:951-493-6699
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANDREA D. ANDERSON, MD., INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90631208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADM992AOtherMEDICARE PTAN #