Provider Demographics
NPI:1760538037
Name:ANDERSON, RUSSELL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78270 HIGHWAY 1081
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-4646
Mailing Address - Country:US
Mailing Address - Phone:985-867-5680
Mailing Address - Fax:
Practice Address - Street 1:78270 HIGHWAY 1081
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435-4646
Practice Address - Country:US
Practice Address - Phone:985-867-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAR042107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1696684Medicaid
5Y479Medicare ID - Type Unspecified
LA1696684Medicaid