Provider Demographics
NPI:1831531557
Name:SO, ANDREA C (OD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:C
Last Name:SO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 REGENT ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1248
Mailing Address - Country:US
Mailing Address - Phone:608-282-2000
Mailing Address - Fax:608-282-2172
Practice Address - Street 1:1025 REGENT ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1248
Practice Address - Country:US
Practice Address - Phone:608-282-2000
Practice Address - Fax:608-282-2172
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14890152W00000X
WI3316-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1831531557Medicaid
WI741501992Medicare PIN