Provider Demographics
NPI:1063472504
Name:FOTHERGILL, RUSSELL EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:EUGENE
Last Name:FOTHERGILL
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:1713 SW H K DODGEN LOOP STE 100
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1836
Practice Address - Country:US
Practice Address - Phone:254-771-8100
Practice Address - Fax:254-771-8101
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2890207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1659237-01OtherCSHCN
TX1659237-01Medicaid
TXP00195392OtherRR/MEDICARE
TX8P1481OtherBLUE SHIELD
TX8C0078Medicare ID - Type Unspecified
TX8P1481OtherBLUE SHIELD