Provider Demographics
NPI:1336142553
Name:RUSSELL, JONATHAN R (MD)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:R
Last Name:RUSSELL
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 1:18220 STATE HIGHWAY 249 STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4370
Mailing Address - Country:US
Mailing Address - Phone:832-698-5500
Mailing Address - Fax:
Practice Address - Street 1:10130 LOUETTA RD
Practice Address - Street 2:SUITE G
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-2118
Practice Address - Country:US
Practice Address - Phone:832-698-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-08-21
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
TXL0557174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8FX325OtherBLUE CROSS BLUE SHIELD
TX1336142553OtherBLUE CROSS BLUE SHIELD
TX143751903Medicaid
TX143751904Medicaid
TX143751904Medicaid
TX501606ZSWDMedicare PIN
TX143751903Medicaid