Provider Demographics
NPI:1306860754
Name:FILLMORE, RUSSELL S (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1164 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-2254
Mailing Address - Country:US
Mailing Address - Phone:419-756-0500
Mailing Address - Fax:
Practice Address - Street 1:1164 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2254
Practice Address - Country:US
Practice Address - Phone:419-756-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4193T1387152WP0200X, 152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0811607Medicaid
U06525Medicare UPIN
FI0740773Medicare ID - Type Unspecified