Provider Demographics
NPI:1215049390
Name:SACKNOFF, ANDREA L (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:L
Last Name:SACKNOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WEST CARVER ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-421-0020
Mailing Address - Fax:631-421-5991
Practice Address - Street 1:200 WEST CARVER ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-421-0020
Practice Address - Fax:631-421-5991
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1797661207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
112234962OtherTAX ID
00110970OtherRRMC
3C1456OtherHEALTHNET
AS03V12910OtherBLUE CROSS BLUE SHIELD
74976OtherVYTRA
179766OtherMEDICAL LICENSE NUMBER
394971OtherCONNECTICARE
P2069468OtherOXFORD
179766OtherHIP
1797661OtherSTATE LICENSE #
112234962OtherTRICARE
1183411OtherUNITED
2611409OtherAETNA
3C1456OtherCARECORE
PP50275OtherMDNY
NY01608740Medicaid
112234962OtherCIGNA
112234962OtherCIGNA
112234962OtherTAX ID
77F631Medicare ID - Type Unspecified