Provider Demographics
NPI:1891803599
Name:GAULT, ANDREA (DO)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:GAULT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:804-217-7991
Practice Address - Street 1:2051 WEST ST
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3006
Practice Address - Country:US
Practice Address - Phone:443-603-0758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65060207P00000X
WV2180207P00000X, 207Q00000X
MDD36761207Q00000X
MDH0060072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1923578OtherAETNA CAPITATED
MD7387630OtherAETNA- FEE FOR SERVICE
MD2717215OtherUNITED HEALTHCARE
MD8200372OtherMAMSI- PRIMARY CARE
MDP00875673OtherRAILROAD MEDICARE
MD2200372OtherMAMSI- SPECIALIST
MD7605-0099OtherCAREFIRST
MD893418-05OtherCAREFIRST MD RENDERING
MD224132OtherJHHC- PROVIDER NUMBER
MD415385500Medicaid
MD7605-0099OtherBLUE CHOICE
MDP18266OtherCAREFIRST MPOS
MD2717215OtherUNITED HEALTHCARE
MDP18266OtherCAREFIRST MPOS
MDH95050Medicare UPIN