Provider Demographics
NPI:1619921608
Name:DEMAGGIO, ANDREW J (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:DEMAGGIO
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 1:725 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201
Mailing Address - Country:US
Mailing Address - Phone:413-447-2752
Mailing Address - Fax:413-496-6836
Practice Address - Street 1:165 TOR CT
Practice Address - Street 2:PAIN CENTER
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-3001
Practice Address - Country:US
Practice Address - Phone:413-445-7246
Practice Address - Fax:413-445-7731
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225796208100000X
MA218719208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2060957Medicaid
MA2060957Medicaid
H23907Medicare UPIN