Provider Demographics
NPI:1760836829
Name:MACIAS MENDOZA, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MACIAS MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:MACIAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100254
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0254
Mailing Address - Country:US
Mailing Address - Phone:352-273-8610
Mailing Address - Fax:352-273-8612
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-1951
Practice Address - Country:US
Practice Address - Phone:352-273-8610
Practice Address - Fax:352-273-8612
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME142622207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107257400Medicaid