Provider Demographics
NPI:1154998078
Name:ANDONIAN, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ANDONIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 OAK ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-8607
Mailing Address - Country:US
Mailing Address - Phone:517-937-1924
Mailing Address - Fax:
Practice Address - Street 1:11550 WARRIOR TRAIL
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240
Practice Address - Country:US
Practice Address - Phone:517-867-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2601001733207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine