Provider Demographics
NPI:1891159596
Name:GILLIS, ANDREA LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:LEIGH
Last Name:GILLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:LEIGH
Other - Last Name:DEDONATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:99 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1207
Mailing Address - Country:US
Mailing Address - Phone:860-714-4129
Mailing Address - Fax:
Practice Address - Street 1:99 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1207
Practice Address - Country:US
Practice Address - Phone:860-714-4212
Practice Address - Fax:860-714-8080
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
CT238113450390200000X
CT63741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program