Provider Demographics
NPI:1669420899
Name:MACANDREW, VINCENT I JR (MD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:I
Last Name:MACANDREW
Suffix:JR
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 1:150 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2026
Mailing Address - Country:US
Mailing Address - Phone:860-456-3997
Mailing Address - Fax:860-450-7323
Practice Address - Street 1:150 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2026
Practice Address - Country:US
Practice Address - Phone:860-456-3997
Practice Address - Fax:860-450-7323
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044039207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E99082Medicare UPIN