Provider Demographics
NPI:1083683908
Name:HANAN, RUSSELL LEON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LEON
Last Name:HANAN
Suffix:JR
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 1:400 NW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103
Mailing Address - Country:US
Mailing Address - Phone:405-235-3245
Mailing Address - Fax:405-235-6991
Practice Address - Street 1:400 NW 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103
Practice Address - Country:US
Practice Address - Phone:405-235-3245
Practice Address - Fax:405-235-6991
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10300208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100105740AMedicaid
OK100105740AMedicaid