Provider Demographics
NPI:1639140700
Name:DEJEAN, ANDRE TODD (MD)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:TODD
Last Name:DEJEAN
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 1:500 OLD RIVER RD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-9504
Mailing Address - Country:US
Mailing Address - Phone:661-664-1230
Mailing Address - Fax:661-716-5484
Practice Address - Street 1:500 OLD RIVER RD
Practice Address - Street 2:SUITE 155
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-9504
Practice Address - Country:US
Practice Address - Phone:661-664-1230
Practice Address - Fax:661-663-3008
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098449207Q00000X
IL036-098449207PE0004X
WAMD60059543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098449Medicaid
ILH79050Medicare UPIN