Provider Demographics
NPI:1508132762
Name:HOSTETLER, RUSSELL MERRITTT (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MERRITTT
Last Name:HOSTETLER
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 1:2514 W VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6326
Mailing Address - Country:US
Mailing Address - Phone:813-877-1370
Mailing Address - Fax:
Practice Address - Street 1:2514 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6326
Practice Address - Country:US
Practice Address - Phone:813-877-1370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 60537207Q00000X
SCMD 30287207Q00000X
MDD0069526207Q00000X
MS20137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FH3099466OtherDEA REGISTRATION #
D29798Medicare UPIN