Provider Demographics
NPI:1467418418
Name:RUSSELL, COREY B (DPM)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:B
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 W SYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-4135
Mailing Address - Country:US
Mailing Address - Phone:419-473-0125
Mailing Address - Fax:419-473-1230
Practice Address - Street 1:3055 W SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-4135
Practice Address - Country:US
Practice Address - Phone:419-473-0125
Practice Address - Fax:419-473-1230
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002914213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2071109Medicaid
OHRU0856681Medicare PIN
OH2071109Medicaid