Provider Demographics
NPI:1609841956
Name:NINICHUCK, ANDREW JOHN (MD)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JOHN
Last Name:NINICHUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 BENHAM ST
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1205
Mailing Address - Country:US
Mailing Address - Phone:573-358-9119
Mailing Address - Fax:573-358-9489
Practice Address - Street 1:527 BENHAM ST
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1205
Practice Address - Country:US
Practice Address - Phone:573-358-9119
Practice Address - Fax:573-358-9489
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102387208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1609841956Medicaid
130700001Medicare PIN