Healthcare Provider Details

I. General information

NPI: 1639140700
Provider Name (Legal Business Name): ANDRE TODD DEJEAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 OLD RIVER RD SUITE 155
BAKERSFIELD CA
93311-9504
US

IV. Provider business mailing address

500 OLD RIVER RD SUITE 155
BAKERSFIELD CA
93311-9504
US

V. Phone/Fax

Practice location:
  • Phone: 661-664-1230
  • Fax: 661-663-3008
Mailing address:
  • Phone: 661-664-1230
  • Fax: 661-716-5484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036098449
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036-098449
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: