Healthcare Provider Details

I. General information

NPI: 1881888345
Provider Name (Legal Business Name): IDEN DAVID ANDACHEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 INDIANA AVE STE 100
RIVERSIDE CA
92504-4557
US

IV. Provider business mailing address

7111 INDIANA AVE STE 100
RIVERSIDE CA
92504-4557
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-9012
  • Fax: 951-276-9163
Mailing address:
  • Phone: 951-276-9012
  • Fax: 951-276-9163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA106941
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA106941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: