Provider Demographics
NPI:1902849755
Name:GANELES, ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:GANELES
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 1:381 HOPMEADOW ST
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-9692
Mailing Address - Country:US
Mailing Address - Phone:860-651-1166
Mailing Address - Fax:860-651-1167
Practice Address - Street 1:381 HOPMEADOW ST
Practice Address - Street 2:SUITE 101B
Practice Address - City:WEATOGUE
Practice Address - State:CT
Practice Address - Zip Code:06089-9692
Practice Address - Country:US
Practice Address - Phone:860-651-1166
Practice Address - Fax:860-651-1167
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001356113Medicaid
CT110008660Medicare ID - Type Unspecified
CT001356113Medicaid