Provider Demographics
NPI:1114218492
Name:RUSSELL, DEMAURA H (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMAURA
Middle Name:H
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEMAURA
Other - Middle Name:KENET
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:702 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4755
Mailing Address - Country:US
Mailing Address - Phone:336-599-9271
Mailing Address - Fax:336-599-0347
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4755
Practice Address - Country:US
Practice Address - Phone:336-599-9271
Practice Address - Fax:336-599-0347
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01723207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114218492Medicaid
NCNCE348AMedicare Oscar/Certification