Provider Demographics
NPI:1861427197
Name:BOLOGNA, ANDREA ELLIE (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:ELLIE
Last Name:BOLOGNA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10429 N MACARTHUR BLVD
Mailing Address - Street 2:APT 161
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063
Mailing Address - Country:US
Mailing Address - Phone:214-801-2977
Mailing Address - Fax:
Practice Address - Street 1:4540 BELT LINE ROAD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001
Practice Address - Country:US
Practice Address - Phone:972-789-9333
Practice Address - Fax:972-789-9557
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10196111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V08462Medicare UPIN
TX8F2368Medicare ID - Type UnspecifiedPROVIDER NUMBER