Provider Demographics
NPI:1730145814
Name:ANDRADA, EDWARD L (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:ANDRADA
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 1:101 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3363
Mailing Address - Country:US
Mailing Address - Phone:479-968-2345
Mailing Address - Fax:479-890-2467
Practice Address - Street 1:101 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3363
Practice Address - Country:US
Practice Address - Phone:479-968-2345
Practice Address - Fax:479-890-2467
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3825207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152300001Medicaid
AR152300001Medicaid
AR5M736Medicare PIN