Healthcare Provider Details

I. General information

NPI: 1699789891
Provider Name (Legal Business Name): KIRK G ANDRUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 MAIN ST
KELSEYVILLE CA
95451-8941
US

IV. Provider business mailing address

4135 MAIN ST
KELSEYVILLE CA
95451-8941
US

V. Phone/Fax

Practice location:
  • Phone: 707-279-1888
  • Fax: 707-279-2832
Mailing address:
  • Phone: 707-279-1888
  • Fax: 707-279-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG34543
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG34543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: