Healthcare Provider Details

I. General information

NPI: 1467668145
Provider Name (Legal Business Name): ANDREW JAMES TERRANELLA MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20963 SPANISH GRANT DR
SONORA CA
95370-9500
US

IV. Provider business mailing address

20963 SPANISH GRANT DR
SONORA CA
95370-9500
US

V. Phone/Fax

Practice location:
  • Phone: 989-528-0795
  • Fax:
Mailing address:
  • Phone: 989-528-0795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36965
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC140785
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier060012
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: