Provider Demographics
NPI:1508307448
Name:RUSSELL, GEORGE WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WILLIAM
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-3094
Mailing Address - Country:US
Mailing Address - Phone:580-924-5500
Mailing Address - Fax:580-924-1991
Practice Address - Street 1:1600 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3094
Practice Address - Country:US
Practice Address - Phone:580-924-5500
Practice Address - Fax:580-924-1991
Is Sole Proprietor?:No
Enumeration Date:2017-03-11
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine