Provider Demographics
NPI:1811920895
Name:ANDRISANI, DAVID L (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:ANDRISANI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15800 PINES BLVD
Mailing Address - Street 2:# 329
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1212
Mailing Address - Country:US
Mailing Address - Phone:954-662-5005
Mailing Address - Fax:
Practice Address - Street 1:15800 PINES BLVD
Practice Address - Street 2:# 329
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1212
Practice Address - Country:US
Practice Address - Phone:954-662-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269849800Medicaid
FL269849800Medicaid
FLH59406Medicare UPIN