Provider Demographics
NPI:1912087024
Name:STANITSAS, ANDREW (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:STANITSAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 MAINWAY DR
Mailing Address - Street 2:
Mailing Address - City:ROSSMOOR
Mailing Address - State:CA
Mailing Address - Zip Code:90720-4815
Mailing Address - Country:US
Mailing Address - Phone:562-397-3811
Mailing Address - Fax:562-493-3971
Practice Address - Street 1:3121 MAINWAY DR
Practice Address - Street 2:
Practice Address - City:ROSSMOOR
Practice Address - State:CA
Practice Address - Zip Code:90720-4815
Practice Address - Country:US
Practice Address - Phone:562-397-3811
Practice Address - Fax:562-493-3971
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6873207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00659934Medicare PIN
CABD394ZMedicare PIN
CAG36766Medicare UPIN
CABD394YMedicare PIN
CAW20A6873CMedicare PIN
CABD394WMedicare PIN