Provider Demographics
NPI:1033372784
Name:IMBODEN, RUSSELL TODD (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:TODD
Last Name:IMBODEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 STOCKELL DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1201
Mailing Address - Country:US
Mailing Address - Phone:636-938-7600
Mailing Address - Fax:636-938-7602
Practice Address - Street 1:14 STOCKELL DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-1201
Practice Address - Country:US
Practice Address - Phone:636-938-7600
Practice Address - Fax:636-938-7602
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9H24207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242531325Medicaid
MO242531325Medicaid