Provider Demographics
NPI:1316010572
Name:RUSSELL, TRACY OWEN (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:OWEN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 SE WASHINGTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-8338
Mailing Address - Country:US
Mailing Address - Phone:918-333-3363
Mailing Address - Fax:918-333-5539
Practice Address - Street 1:2523 SE WASHINGTON BLVD.
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-8338
Practice Address - Country:US
Practice Address - Phone:918-333-3363
Practice Address - Fax:918-333-5539
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDF3888OtherPALMETTO#
OKDF3888OtherPALMETTO#
OK$$$$$$$$$Medicare PIN
OK900522108Medicare PIN