Provider Demographics
NPI:1811395676
Name:ANDES, GREG
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:ANDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 NE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3222
Mailing Address - Country:US
Mailing Address - Phone:570-506-2383
Mailing Address - Fax:
Practice Address - Street 1:1931 NE 15TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-3222
Practice Address - Country:US
Practice Address - Phone:570-506-2383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist