Provider Demographics
NPI:1033453212
Name:UNDERWOOD, RUSSEL WAYNE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:WAYNE
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 SPLIT OAK LN APT H
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5295
Mailing Address - Country:US
Mailing Address - Phone:804-288-2052
Mailing Address - Fax:
Practice Address - Street 1:1523 SPLIT OAK LN APT H
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23229-5295
Practice Address - Country:US
Practice Address - Phone:804-288-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist