Provider Demographics
NPI:1548381049
Name:NIEWALD, ANDREW JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JONATHAN
Last Name:NIEWALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 502
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5169
Mailing Address - Country:US
Mailing Address - Phone:386-231-3570
Mailing Address - Fax:386-231-3571
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 502
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-231-3570
Practice Address - Fax:386-231-3571
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206336307Medicaid
H69F428Medicare PIN