Provider Demographics
NPI:1982682381
Name:ANDICH, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
Last Name:ANDICH
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 1:88 MADRONE ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-4249
Mailing Address - Country:US
Mailing Address - Phone:707-459-6115
Mailing Address - Fax:
Practice Address - Street 1:88 MADRONE ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4249
Practice Address - Country:US
Practice Address - Phone:707-459-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G231090OtherMEDICARE ID-TYPE UNSPECIFIED
CAA41856Medicare UPIN