Provider Demographics
NPI:1629090899
Name:ANDRUS, CAROL ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:ANDRUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-3025
Mailing Address - Country:US
Mailing Address - Phone:361-552-0325
Mailing Address - Fax:361-552-5926
Practice Address - Street 1:1016 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-3000
Practice Address - Country:US
Practice Address - Phone:361-552-0325
Practice Address - Fax:361-552-5926
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTXK0057207Q00000X
TXK0057207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK0057OtherSTATE BOARD OF MEDICINE
TX173721501Medicaid
TX30095257OtherDPS
TX8D5106Medicare ID - Type Unspecified
TXQ35809Medicare UPIN