Provider Demographics
NPI:1609097260
Name:ANDERSON, RUSSELL D (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 NORTH OAKWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-4946
Mailing Address - Country:US
Mailing Address - Phone:580-234-2700
Mailing Address - Fax:580-234-3338
Practice Address - Street 1:128 NORTH OAKWOOD ROAD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-4946
Practice Address - Country:US
Practice Address - Phone:580-234-2700
Practice Address - Fax:580-234-3338
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3418111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU69994Medicare UPIN