Provider Demographics
NPI:1467529834
Name:RUSSELL, RICHARD RAWLS (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RAWLS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S ODOM ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4631
Mailing Address - Country:US
Mailing Address - Phone:318-281-2200
Mailing Address - Fax:318-281-7359
Practice Address - Street 1:210 S ODOM ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4631
Practice Address - Country:US
Practice Address - Phone:318-281-2200
Practice Address - Fax:318-281-7359
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA872-292T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1308021Medicaid
2267BOtherBLUE CROSS BLUE SHIELD OF LOUISIANA
72128OtherVANTAGE HEALTH PLAN
30048OtherUNITED COMMERCIAL TRAVELORS OF AMERICA
98171OtherARKANSAS BLUE CROSS BLUE SHIELD
30048OtherUNITED COMMERCIAL TRAVELORS OF AMERICA
2267BOtherBLUE CROSS BLUE SHIELD OF LOUISIANA