Basic Information
| Provider Information | |||||||||
| NPI: | 1356305171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDREYEVA | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059136130 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059136130 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 206648 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD2013-0072 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000008340 | 01 | MA | PROVIDER HEALTHNET NUMBER | OTHER | 3968488 | 01 | MA | PROVIDER AETNA NUMBER | OTHER | BA7045328 | 01 | MA | DEA # | OTHER | 1745138001 | 01 | MA | PROVIDER CIGNA NUMBER | OTHER | 2132966 | 05 | MA | MEDICAID | J23355 | 01 | MA | BC/BS | OTHER | 1310097 | 05 | MA | MEDICAID | 975513 | 01 | MA | PROVIDER NETWORK HEALTH # | OTHER | MA0423703A | 01 | MA | PROVIDER CSR # | OTHER | 691829 | 01 | MA | PROVIDER HARVARD PILGRIM | OTHER | 206648 | 01 | PROVIDER CONNECTICARE # | OTHER | 0023361 | 01 | MA | PROVIDER NHP NUMBER | OTHER | 206648 | 01 | MA | PROVIDE LICENSE # | OTHER |