Provider Demographics
NPI:1326196593
Name:RUSSELL, RICHARD DEWAYNE
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DEWAYNE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 BOONE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7388
Mailing Address - Country:US
Mailing Address - Phone:501-504-2126
Mailing Address - Fax:501-504-2126
Practice Address - Street 1:3165 BOONE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7388
Practice Address - Country:US
Practice Address - Phone:501-504-2126
Practice Address - Fax:501-504-2126
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMG00708332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5399440001Medicare NSC