Provider Demographics
NPI:1588666119
Name:HAYDUKE, ANDREW J (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:HAYDUKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:KIEWIT SUITE 206
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-341-6996
Mailing Address - Fax:760-341-6776
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:KIEWIT SUITE 206
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-341-6996
Practice Address - Fax:760-341-6776
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70532208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A705320OtherBLUE SHIELD PROVIDER #
CA00A705320OtherBLUE SHIELD PROVIDER #
CAH63692Medicare UPIN