Provider Demographics
NPI:1972602761
Name:SAMPLE, ANDREA R (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:R
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:R
Other - Last Name:JEFFERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12277 DE PAUL DR STE 305
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2529
Practice Address - Country:US
Practice Address - Phone:314-344-7585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006012211174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006012211OtherMISSOUIR LICENSE