Provider Demographics
NPI:1386671543
Name:RUSSELL, ROBERT C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
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 1:431 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-2933
Mailing Address - Country:US
Mailing Address - Phone:318-377-8855
Mailing Address - Fax:318-371-1170
Practice Address - Street 1:431 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-2933
Practice Address - Country:US
Practice Address - Phone:318-377-8855
Practice Address - Fax:318-371-1170
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020174174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1932132Medicaid
LAF22591Medicare UPIN