Provider Demographics
NPI:1467454322
Name:RUSSELL, ANTHONY OTIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:OTIS
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 1:1633 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4620
Mailing Address - Country:US
Mailing Address - Phone:850-431-3276
Mailing Address - Fax:
Practice Address - Street 1:1633 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4620
Practice Address - Country:US
Practice Address - Phone:850-431-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127853207LA0401X, 207LP2900X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018286400Medicaid
NC2177294Medicare PIN