Provider Demographics
NPI:1487751046
Name:MANN, ANDREA PAX (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:PAX
Last Name:MANN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 SOUTH GREEN ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121
Mailing Address - Country:US
Mailing Address - Phone:216-291-9210
Mailing Address - Fax:216-291-9422
Practice Address - Street 1:2054 SOUTH GREEN ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121
Practice Address - Country:US
Practice Address - Phone:216-291-9210
Practice Address - Fax:216-291-9422
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-8060-M207RA0000X
OH3400806207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2408693Medicaid
OHH88322Medicare UPIN
OHMA7313951Medicare ID - Type Unspecified