Provider Demographics
NPI:1346594439
Name:SMITH, RUSSELL ALAN (CNIM, REPT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CNIM, REPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 JAY ELL DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-1837
Mailing Address - Country:US
Mailing Address - Phone:888-344-2947
Mailing Address - Fax:888-694-2947
Practice Address - Street 1:1819 JAY ELL DR # 1
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-1837
Practice Address - Country:US
Practice Address - Phone:888-344-2947
Practice Address - Fax:888-694-2947
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1151246ZE0600X
TX2557246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic