Provider Demographics
NPI:1942264288
Name:RADEBOLD, ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RADEBOLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3730
Mailing Address - Country:US
Mailing Address - Phone:203-488-6358
Mailing Address - Fax:203-481-5327
Practice Address - Street 1:960 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3730
Practice Address - Country:US
Practice Address - Phone:203-488-6358
Practice Address - Fax:203-481-5327
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042296207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010042296CT01OtherANTHEM BCBS
P00140199OtherRAILROAD MEDICARE
CT001422964Medicaid
042296OtherCONNECTICARE
3680171OtherAETNA
0Q2728OtherHEALTHNET
P3340613OtherOXFORD
042296OtherCONNECTICARE
P3340613OtherOXFORD