Provider Demographics
NPI:1265498976
Name:STAPLETON, RUSSELL B (MD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:B
Last Name:STAPLETON
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:PO BOX 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-720-0799
Mailing Address - Fax:904-398-2480
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 112
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-396-5996
Practice Address - Fax:904-398-2480
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69903207RI0011X, 207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060071306OtherRAILROAD MEDICARE
FL250604100Medicaid
FL060071306OtherRAILROAD MEDICARE
FL28930TMedicare PIN