Provider Demographics
NPI:1457413858
Name:ANDELIN, PAUL BERRY (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:BERRY
Last Name:ANDELIN
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 1:1937 W CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-1977
Mailing Address - Country:US
Mailing Address - Phone:417-678-6328
Mailing Address - Fax:417-678-4028
Practice Address - Street 1:203 S WASHINGTON AVE STE A
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-1466
Practice Address - Country:US
Practice Address - Phone:417-678-4022
Practice Address - Fax:417-678-4028
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR3M76207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine