Provider Demographics
NPI:1821029786
Name:DEANDREA A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DEANDREA A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DEANDREA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-552-5000
Mailing Address - Street 1:1101 N PACIFIC AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-4313
Mailing Address - Country:US
Mailing Address - Phone:818-552-5000
Mailing Address - Fax:818-552-2959
Practice Address - Street 1:1101 N PACIFIC AVE STE 104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-4313
Practice Address - Country:US
Practice Address - Phone:818-552-5000
Practice Address - Fax:818-552-2959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG74640OtherLICENSE
CAG74640OtherLICENSE
CAF65798Medicare UPIN