Provider Demographics
NPI:1033144225
Name:RUSSELL, GREGORY CLINTON (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CLINTON
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 PROFESSIONAL PARK PVT DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2287
Mailing Address - Country:US
Mailing Address - Phone:423-245-2222
Mailing Address - Fax:423-245-4822
Practice Address - Street 1:102 PROFESSIONAL PARK PVT DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2287
Practice Address - Country:US
Practice Address - Phone:423-245-2222
Practice Address - Fax:423-245-4822
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1813152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3941713Medicaid
TN4076931OtherBLUE CROSS BLUE SHIELD OF
TN3941713Medicare ID - Type Unspecified
TN4076931OtherBLUE CROSS BLUE SHIELD OF