Healthcare Provider Details

I. General information

NPI: 1407235955
Provider Name (Legal Business Name): ANDRE ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23450 VIA COCONUT PT
ESTERO FL
34135-1877
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-0150
  • Fax: 239-343-4056
Mailing address:
  • Phone: 239-468-0150
  • Fax: 239-343-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME136218
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME136218
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11018468A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: