Provider Demographics
NPI:1003918137
Name:RUSSELL, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2731 OAK BLUFF
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230
Mailing Address - Country:US
Mailing Address - Phone:210-492-9131
Mailing Address - Fax:210-492-9131
Practice Address - Street 1:2731 OAK BLUFF
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230
Practice Address - Country:US
Practice Address - Phone:210-492-9131
Practice Address - Fax:210-492-9131
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD0279208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
C21432Medicare UPIN
TXC21432Medicare ID - Type Unspecified