Provider Demographics
NPI:1598718876
Name:ANDRIAS, C WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:WALLACE
Last Name:ANDRIAS
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 1:88 PAYER LN
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:860-822-3547
Mailing Address - Fax:
Practice Address - Street 1:235 LESTERTOWN RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2808
Practice Address - Country:US
Practice Address - Phone:860-822-3547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20133207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060014262OtherRR MED/ECCG: 06-1049086
500HBC444CT01OtherANTHEM/HOSP-BASED ECCD
0V9740OtherHEALTHNET/ECCD:06-1616101
NLS101OtherOXFORD/ECCG: 06-1049086
001201334OtherBLUECARE FAMILY PLAN
030265OtherHEALTHNET/ECCG:06-1049086
CT001201334Medicaid
010020133CT02OtherANTHEM/ECCG:06-1049086
060064826OtherRR MED/ECCD: 06-1616101
P2524339OtherOXFORD/ECCD: 06-1616101
010020133CT06OtherANTHEM/ECCD:06-1616101
020133OtherCONNECTICARE
B38240Medicare UPIN
060000260Medicare ID - Type UnspecifiedECCG: 06-1049086
060064826OtherRR MED/ECCD: 06-1616101