Provider Demographics
NPI:1154332476
Name:RUSSELL, JEFFREY B (MD, FACOG)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD, FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 OGLETOWN STANTON RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2067
Mailing Address - Country:US
Mailing Address - Phone:302-738-4600
Mailing Address - Fax:302-738-3508
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 111
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-738-4600
Practice Address - Fax:302-738-3508
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002852DE174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC48780Medicare UPIN