Provider Demographics
NPI:1972062701
Name:ITO, ANDREA (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ITO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 21ST AVENUE SOUTH
Mailing Address - Street 2:MCN A-2206
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1161 21ST AVENUE SOUTH
Practice Address - Street 2:MCN A-2206
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232
Practice Address - Country:US
Practice Address - Phone:615-343-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN71280207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2495127Medicaid