Provider Demographics
NPI:1497863906
Name:MASCARENHAS, RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:MASCARENHAS
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 1:107 1/2 SWIFT ST
Mailing Address - Street 2:
Mailing Address - City:REFUGIO
Mailing Address - State:TX
Mailing Address - Zip Code:78377-2425
Mailing Address - Country:US
Mailing Address - Phone:361-526-5328
Mailing Address - Fax:361-526-5670
Practice Address - Street 1:107 1/2 SWIFT ST
Practice Address - Street 2:
Practice Address - City:REFUGIO
Practice Address - State:TX
Practice Address - Zip Code:78377-2425
Practice Address - Country:US
Practice Address - Phone:361-526-5328
Practice Address - Fax:361-526-5670
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121272202Medicaid
TXK0920OtherSTATE MEDICAL LICENSE
TX8046J4Medicare PIN
TX121272202Medicaid