Basic Information
| Provider Information | |||||||||
| NPI: | 1811359508 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADIEDO | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | MARCELA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 GARDNER ST APT 31 | ||||||||
| Address2: | |||||||||
| City: | ALLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021342243 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7765 SW 87TH AVE STE 212 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331732586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055963080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208C00000X | ME156548 | FL | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.