Individual
DR. MANDY R RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
650 LINDEN ST, SUITE 5, BIG RAPIDS, MI 49307-1879
(231) 796-0010
(231) 796-2496
Mailing address
20665 BLUE FOX WAY, HOWARD CITY, MI 49329
(231) 340-0112
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
4901004360
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0E40038
BCBSM
MI
01
—
CG0293
MEDICARE RAILROAD
—
Enumeration date
01/31/2007
Last updated
05/13/2011
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