Provider Demographics
NPI:1609495886
Name:MASSABAND, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MASSABAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 MIDVALE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5512
Mailing Address - Country:US
Mailing Address - Phone:310-963-3929
Mailing Address - Fax:
Practice Address - Street 1:11375 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5409
Practice Address - Country:US
Practice Address - Phone:352-596-6632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME161290208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice