Provider Demographics
NPI:1376734210
Name:WARDLAW, RUSSELL J (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:WARDLAW
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 1:16061 DOCTORS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1499
Mailing Address - Country:US
Mailing Address - Phone:985-542-1334
Mailing Address - Fax:985-893-9594
Practice Address - Street 1:16061 DOCTORS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1499
Practice Address - Country:US
Practice Address - Phone:985-542-1334
Practice Address - Fax:985-893-9594
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1056529Medicaid
LA1056529Medicaid