Provider Demographics
NPI:1508029497
Name:RUSSELL, WESLEY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:ALAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7910 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-436-4116
Mailing Address - Fax:260-459-2504
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-9100
Practice Address - Fax:260-266-9110
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2018-06-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01072532A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201163340Medicaid
OH0083773Medicaid
MI1508029497Medicaid
MI1508029497Medicaid