Provider Demographics
NPI:1508950379
Name:RUSSELL, JAMES (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:RUSSELL
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 1:308 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4110
Mailing Address - Country:US
Mailing Address - Phone:918-224-3081
Mailing Address - Fax:918-224-5059
Practice Address - Street 1:308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4110
Practice Address - Country:US
Practice Address - Phone:918-224-3081
Practice Address - Fax:918-224-5059
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100134450AMedicaid
100134450BOtherSOONERCARE
OK100134450AMedicaid
100134450BOtherSOONERCARE
OK$$$$$$$$$Medicare PIN