Provider Demographics
NPI:1487656237
Name:RUSSELL, GREGG E (OD)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:E
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 1:895 CANTON RD NE
Mailing Address - Street 2:BUILDING 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8934
Mailing Address - Country:US
Mailing Address - Phone:770-427-8111
Mailing Address - Fax:770-499-1643
Practice Address - Street 1:895 CANTON RD NE
Practice Address - Street 2:BUILDING 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8934
Practice Address - Country:US
Practice Address - Phone:770-427-8111
Practice Address - Fax:770-499-1643
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000515787WMedicaid
GA41ZCFVMMedicare ID - Type Unspecified
GA000515787WMedicaid