Provider Demographics
NPI:1063610061
Name:ANDROSSOV, ANDREI (MD)
Entity type:Individual
Prefix:
First Name:ANDREI
Middle Name:
Last Name:ANDROSSOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:5230 BOULDER HWY STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122
Practice Address - Country:US
Practice Address - Phone:702-940-1560
Practice Address - Fax:702-940-1561
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121765207Q00000X
NV17795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1063610061Medicaid
NV17795OtherSTATE LICENSE