Provider Demographics
NPI:1114981826
Name:FRY, RUSSELL L II (MD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:L
Last Name:FRY
Suffix:II
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:5187 US ROUTE 60 E
Mailing Address - Street 2:STE 6
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2076
Mailing Address - Country:US
Mailing Address - Phone:304-691-8800
Mailing Address - Fax:304-302-0221
Practice Address - Street 1:5187 US ROUTE 60 E
Practice Address - Street 2:STE 6
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2076
Practice Address - Country:US
Practice Address - Phone:304-691-8800
Practice Address - Fax:304-302-0221
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200501699207W00000X
WV21418207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902537Medicaid
I08679Medicare UPIN