Provider Demographics
NPI:1629160262
Name:ANDOM, TEDROS (MD)
Entity Type:Individual
Prefix:DR
First Name:TEDROS
Middle Name:
Last Name:ANDOM
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 1:2253 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2736
Mailing Address - Country:US
Mailing Address - Phone:937-717-4884
Mailing Address - Fax:937-717-6207
Practice Address - Street 1:2253 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2736
Practice Address - Country:US
Practice Address - Phone:937-717-4884
Practice Address - Fax:937-717-6207
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35091693208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2850571Medicaid
OH2850571Medicaid