Provider Demographics
NPI:1255307278
Name:RUSSELL, ALAN S (OD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:613-858-3830
Practice Address - Street 1:8111 E HARRY
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207
Practice Address - Country:US
Practice Address - Phone:316-685-7661
Practice Address - Fax:316-685-0227
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS1040-2152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS014709Medicare PIN
KST43751Medicare UPIN