Provider Demographics
NPI:1942281159
Name:MAXWELL, ANDREW LEROY (OD)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:LEROY
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2040
Mailing Address - Country:US
Mailing Address - Phone:334-793-2211
Mailing Address - Fax:
Practice Address - Street 1:2826 ROSS CLARK CIR STE 102
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2017
Practice Address - Country:US
Practice Address - Phone:334-793-2633
Practice Address - Fax:334-794-1626
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS547TA203152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059847Medicaid
AL051059847OtherBCBS