Healthcare Provider Details

I. General information

NPI: 1104863745
Provider Name (Legal Business Name): ANDREW B CIVITELLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 CAMBRIDGE ST FL 6
HOUSTON TX
77030-4202
US

IV. Provider business mailing address

6620 MAIN ST STE 11A23.4
HOUSTON TX
77030-2348
US

V. Phone/Fax

Practice location:
  • Phone: 713-798-2545
  • Fax: 713-798-2578
Mailing address:
  • Phone: 713-798-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberK4661
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberK4661
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: