Healthcare Provider Details

I. General information

NPI: 1548407513
Provider Name (Legal Business Name): RUSSELL STEVEN ANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N MAIN ST
TOOELE UT
84074-1611
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 435-843-2364
  • Fax: 435-228-0062
Mailing address:
  • Phone: 435-743-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5148252-8904
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5148252-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: