Provider Demographics
NPI:1508139676
Name:ANDREA D. ANDERSON, MD., INC.
Entity type:Organization
Organization Name:ANDREA D. ANDERSON, MD., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-268-8120
Mailing Address - Street 1:PO BOX 6146
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-6146
Mailing Address - Country:US
Mailing Address - Phone:951-268-8120
Mailing Address - Fax:951-493-1919
Practice Address - Street 1:2083 COMPTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-7288
Practice Address - Country:US
Practice Address - Phone:951-268-8112
Practice Address - Fax:951-493-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90631208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADM992AOtherMEDICARE PTAN #