Provider Demographics
NPI:1578637245
Name:ANDOH, HENRY M (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:M
Last Name:ANDOH
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 1:761 45TH AVE
Mailing Address - Street 2:STE. 103
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2893
Mailing Address - Country:US
Mailing Address - Phone:219-922-3002
Mailing Address - Fax:219-922-3003
Practice Address - Street 1:757 45TH AVE
Practice Address - Street 2:STE. 201
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2911
Practice Address - Country:US
Practice Address - Phone:219-934-2461
Practice Address - Fax:219-934-2478
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-083429207RI0200X
IN01042402A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110108462OtherRAILROAD MEDICARE
IL0001606805OtherBLUE CROSS BLUE SHIELD
IL0004542266OtherAETNA
IN200009960BMedicaid
IL0004542266OtherAETNA
IL110108462OtherRAILROAD MEDICARE
IN200009960BMedicaid