Provider Demographics
NPI:1942936422
Name:ANDRUS, DOUG KENNETH
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:KENNETH
Last Name:ANDRUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 W GEISERMAN RD
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-8507
Mailing Address - Country:US
Mailing Address - Phone:193-754-1127
Mailing Address - Fax:937-778-0568
Practice Address - Street 1:575 W GEISERMAN RD
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-8507
Practice Address - Country:US
Practice Address - Phone:193-754-1127
Practice Address - Fax:937-778-0568
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171WH0202XMedicaid