Provider Demographics
NPI:1861589269
Name:ANDRESIAN, ANDRE (MD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:
Last Name:ANDRESIAN
Suffix:
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 1:420 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1835
Mailing Address - Country:US
Mailing Address - Phone:626-331-6663
Mailing Address - Fax:626-339-8132
Practice Address - Street 1:420 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1835
Practice Address - Country:US
Practice Address - Phone:626-331-6663
Practice Address - Fax:626-339-8132
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25075207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW10650Medicare ID - Type Unspecified
CAE50876Medicare UPIN