Provider Demographics
NPI:1790867026
Name:ANDRONACO, RAYMOND B (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:B
Last Name:ANDRONACO
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 1:177 N DEAN ST # 305
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2533
Mailing Address - Country:US
Mailing Address - Phone:201-569-7777
Mailing Address - Fax:201-569-6861
Practice Address - Street 1:177 N DEAN ST # 305
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2533
Practice Address - Country:US
Practice Address - Phone:201-569-7777
Practice Address - Fax:201-569-6861
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05311600208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJAN549820Medicare ID - Type Unspecified
NJB19790Medicare UPIN