Provider Demographics
NPI:1396273355
Name:IMMANUEL, ANDRE DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:DANIEL
Last Name:IMMANUEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDRE
Other - Middle Name:LEKOUNA
Other - Last Name:TINGU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANDRE LEKOUNA TINGU
Mailing Address - Street 1:400 E MOSHOLU PKWY S APT B5
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1747
Mailing Address - Country:US
Mailing Address - Phone:240-273-6395
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2012
Practice Address - Country:US
Practice Address - Phone:718-270-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine