Provider Demographics
NPI:1699789891
Name:ANDRUS, KIRK G (MD)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:G
Last Name:ANDRUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8941
Mailing Address - Country:US
Mailing Address - Phone:707-279-1888
Mailing Address - Fax:707-279-2832
Practice Address - Street 1:4135 MAIN ST
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-8941
Practice Address - Country:US
Practice Address - Phone:707-279-1888
Practice Address - Fax:707-279-2832
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34543207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G345430Medicaid
CAG34543OtherCA LICENSE
CAG34543OtherCA LICENSE
CAA45967Medicare UPIN
CA00G345430Medicare PIN