Provider Demographics
NPI:1548407513
Name:ANDERSON, RUSSELL STEVEN (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:STEVEN
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:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:435-743-5591
Mailing Address - Fax:
Practice Address - Street 1:777 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1611
Practice Address - Country:US
Practice Address - Phone:435-843-2364
Practice Address - Fax:435-228-0062
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5148252-8904207Q00000X
UT5148252-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1548407513Medicaid
UT1548407513Medicaid