Provider Demographics
NPI:1417019522
Name:WARREN K RUSSELL PH D P C
Entity Type:Organization
Organization Name:WARREN K RUSSELL PH D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-415-2302
Mailing Address - Street 1:717 NW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-6030
Mailing Address - Country:US
Mailing Address - Phone:405-415-2302
Mailing Address - Fax:405-415-2301
Practice Address - Street 1:717 NW 56TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-6030
Practice Address - Country:US
Practice Address - Phone:405-415-2302
Practice Address - Fax:405-415-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK753103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK442526116001OtherBCBS OF OKLAHOMA