Individual
ANDREW RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
925 2ND AVE, MONTE VISTA, CO 81144-1432
(719) 852-2512
(719) 852-3923
Mailing address
925 2ND AVE, MONTE VISTA, CO 81144-1432
(719) 852-2512
(719) 852-3923
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0068003
CO
390200000X
Student in an Organized Health Care Education/Training Program
—
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0068003
LICENSURE
CO
Enumeration date
04/20/2015
Last updated
03/08/2022
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