Provider Demographics
NPI:1255358602
Name:ZANGALADZE, ANDRO T (MD)
Entity type:Individual
Prefix:DR
First Name:ANDRO
Middle Name:T
Last Name:ZANGALADZE
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 1:151 FRIES MILL RD STE 301
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2016
Mailing Address - Country:US
Mailing Address - Phone:856-352-6660
Mailing Address - Fax:
Practice Address - Street 1:200 BOWMAN DR
Practice Address - Street 2:SUITE E385
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9623
Practice Address - Country:US
Practice Address - Phone:856-247-7770
Practice Address - Fax:856-247-7766
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4181392084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001958087Medicaid
NJ0005380Medicaid
PA071951Medicare PIN