Provider Demographics
NPI:1669869558
Name:RUSSELL, ANDREW (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:RUSSELL
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 1:925 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-1432
Mailing Address - Country:US
Mailing Address - Phone:719-852-2512
Mailing Address - Fax:719-852-3923
Practice Address - Street 1:925 2ND AVE
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1432
Practice Address - Country:US
Practice Address - Phone:719-852-2512
Practice Address - Fax:719-852-3923
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
CO0068003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0068003OtherLICENSURE