Provider Demographics
NPI:1194187179
Name:LANDRY, RUSSELL PAUL III (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:PAUL
Last Name:LANDRY
Suffix:III
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 1:1303 US HWY 127 S STE 402, BOX 367
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601
Mailing Address - Country:US
Mailing Address - Phone:713-430-6095
Mailing Address - Fax:
Practice Address - Street 1:651 DUNLOP LANE
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:713-430-6095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51961207P00000X
TN62086207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2414038Medicaid