Provider Demographics
NPI:1730199043
Name:TADDEO, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:TADDEO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8574 BURNET RD
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-9412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1144
Practice Address - Country:US
Practice Address - Phone:315-422-4412
Practice Address - Fax:315-422-4690
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC0038721156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01007758Medicaid
NY34586WMedicare ID - Type Unspecified
NY01007758Medicaid