Provider Demographics
NPI:1477550663
Name:RUSSELL, DAVID P (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1301 PLEASANT VALLEY RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-9774
Mailing Address - Country:US
Mailing Address - Phone:270-417-7880
Mailing Address - Fax:270-417-7888
Practice Address - Street 1:1301 PLEASANT VALLEY RD
Practice Address - Street 2:SUITE 302
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7880
Practice Address - Fax:270-417-7888
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2016-06-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY20218208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000197830OtherBCBS
340001298OtherRAILROAD MEDICARE
KY64-202187Medicaid
B58796Medicare UPIN
000000197830OtherBCBS