Provider Demographics
NPI:1316084965
Name:RUSSELL, MANDY R (OD)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20665 BLUE FOX WAY
Mailing Address - Street 2:
Mailing Address - City:HOWARD CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49329
Mailing Address - Country:US
Mailing Address - Phone:231-340-0112
Mailing Address - Fax:
Practice Address - Street 1:650 LINDEN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1879
Practice Address - Country:US
Practice Address - Phone:231-796-0010
Practice Address - Fax:231-796-2496
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004360152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E40038OtherBCBSM
CG0293OtherMEDICARE RAILROAD
MI1280290002Medicare NSC
CG0293OtherMEDICARE RAILROAD
MIN95880002Medicare PIN