Provider Demographics
NPI:1538471172
Name:RUSSAL, SOBY A (OD)
Entity Type:Individual
Prefix:DR
First Name:SOBY
Middle Name:A
Last Name:RUSSAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2421
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00625100152W00000X
PAOEG002457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist