Provider Demographics
NPI:1558692145
Name:BRETAL, ANDREA VIVIANA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:VIVIANA
Last Name:BRETAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 TOWN CENTER BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3637
Mailing Address - Country:US
Mailing Address - Phone:954-389-1800
Mailing Address - Fax:954-389-7600
Practice Address - Street 1:1605 TOWN CENTER BLVD STE D
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3637
Practice Address - Country:US
Practice Address - Phone:954-389-1800
Practice Address - Fax:954-389-7600
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64777207R00000X
FLME122080261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine