Provider Demographics
NPI:1497724223
Name:RUSSELL, JAMES DAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVIS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1521 N 10TH ST
Mailing Address - Street 2:STE C
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1405
Mailing Address - Country:US
Mailing Address - Phone:870-762-5360
Mailing Address - Fax:870-762-1146
Practice Address - Street 1:1521 N 10TH ST
Practice Address - Street 2:STE C
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1405
Practice Address - Country:US
Practice Address - Phone:870-762-5360
Practice Address - Fax:870-762-1146
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4640208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D04892Medicare UPIN