Provider Demographics
NPI:1568556157
Name:ANDREO, LARRY KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:KENNETH
Last Name:ANDREO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4500 STUART STREET
Mailing Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL, ATTN: MCXL-PQ (CREDE
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5720
Mailing Address - Country:US
Mailing Address - Phone:803-751-2618
Mailing Address - Fax:803-751-2689
Practice Address - Street 1:4500 STUART STREET
Practice Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL, ATTN: MCXL-PQ (CREDE
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5720
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:803-751-2689
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28391207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVAD-000Medicare UPIN