Provider Demographics
NPI:1134112865
Name:FELL, WILLIAM RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:FELL
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 1:3802 22ND
Mailing Address - Street 2:#100
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410
Mailing Address - Country:US
Mailing Address - Phone:806-792-5331
Mailing Address - Fax:806-792-9417
Practice Address - Street 1:3802 22ND
Practice Address - Street 2:#100
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-792-5331
Practice Address - Fax:806-792-9417
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4303207Y00000X
TXJ5090207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD03211Medicaid
TX328541301Medicaid
AK150899Medicare ID - Type UnspecifiedNORIDIAN MEDICARE
TX328541301Medicaid
AKMD03211Medicaid