Healthcare Provider Details

I. General information

NPI: 1932442787
Provider Name (Legal Business Name): ANDREW MUTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 12/16/2022
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PLEASANT ST
DES MOINES IA
50309
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 515-241-5926
  • Fax:
Mailing address:
  • Phone: 585-922-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-45719
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-45719
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: