Provider Demographics
NPI:1679542641
Name:WAXMAN, ANDREA J (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:WAXMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-495-4577
Mailing Address - Fax:602-417-3549
Practice Address - Street 1:925 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2502
Practice Address - Country:US
Practice Address - Phone:602-239-6800
Practice Address - Fax:602-239-6988
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ215212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ299794Medicaid
Z74593Medicare PIN
G02552Medicare UPIN