Provider Demographics
NPI:1619963246
Name:KANNER, ANDRES M (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:M
Last Name:KANNER
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 1:1475 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1002
Mailing Address - Country:US
Mailing Address - Phone:305-243-7520
Mailing Address - Fax:305-243-4678
Practice Address - Street 1:1475 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1002
Practice Address - Country:US
Practice Address - Phone:305-243-7520
Practice Address - Fax:305-243-4678
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360826792084N0400X
FLME1141602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336044952OtherIL DEPT OF PROF REG
IL036082679Medicaid
BK3010066OtherFED DRUG ENFORCEMENT AGEN
A98823Medicare UPIN
IL036082679Medicaid