Provider Demographics
NPI:1578705208
Name:STAACK, ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:STAACK
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-794-7700
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLZ
Practice Address - Street 2:SUITE #140
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5519208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP355Medicare PIN