Basic Information
| Provider Information | |||||||||
| NPI: | 1104863745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIVITELLO | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6620 MAIN ST STE 11A23.4 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137982129 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7200 CAMBRIDGE ST FL 6 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137982545 | ||||||||
| FaxNumber: | 7137982578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | K4661 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | K4661 | TX | Y |
ID Information
| ID | Type | State | Issuer | Description | 038749003 | 05 | TX | MEDICAID |