Individual
BRANDON RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
3640 NEW VISION DRIVE, FORT WAYNE, IN 46845-1717
(260) 482-4440
(260) 482-4442
Mailing address
416 E MAUMEE ST, ANGOLA, IN 46703-2015
(260) 665-2141
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
02003088
IN
207P00000X
Emergency Medicine Physician
Primary
34C.000055
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200825030
—
IN
Enumeration date
06/05/2006
Last updated
12/20/2022
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