Provider Demographics
NPI:1013900810
Name:MICHAEL ANDRISANI MD INC
Entity Type:Organization
Organization Name:MICHAEL ANDRISANI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRISANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-469-3822
Mailing Address - Street 1:8600 LA MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-3972
Mailing Address - Country:US
Mailing Address - Phone:619-469-3822
Mailing Address - Fax:
Practice Address - Street 1:8600 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3972
Practice Address - Country:US
Practice Address - Phone:619-469-3822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA001193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12916136OtherMEDICARE RAILROAD
A39334Medicare UPIN