Healthcare Provider Details

I. General information

NPI: 1700066529
Provider Name (Legal Business Name): KIRK G ANDRUS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 01/05/2009
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: 707-279-2004
  • Fax: 707-279-2832
Mailing address:
  • Phone: 707-279-2204
  • Fax: 707-279-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG34543
License Number StateCA

VIII. Authorized Official

Name: KIRK G ANDRUS
Title or Position: OWNER
Credential: MD
Phone: 707-279-2204