Provider Demographics
NPI:1114939733
Name:ANDERSON, RUSSELL WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 919
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-728-6145
Mailing Address - Fax:918-728-6146
Practice Address - Street 1:4500 S GARNETT RD
Practice Address - Street 2:STE 919
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5229
Practice Address - Country:US
Practice Address - Phone:918-728-6145
Practice Address - Fax:918-728-6146
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056948207P00000X
OK4498207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200115580AMedicaid
OK200115580AMedicaid
OK249724003Medicare PIN