Provider Demographics
NPI:1568414464
Name:STONE, RUSSELL BRYANT (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:BRYANT
Last Name:STONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27393-4421
Mailing Address - Country:US
Mailing Address - Phone:252-243-2020
Mailing Address - Fax:252-291-2020
Practice Address - Street 1:2402 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27393-4421
Practice Address - Country:US
Practice Address - Phone:252-243-2020
Practice Address - Fax:252-291-2020
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093KUMedicaid
NC1568414464OtherNPI
NC2200355OtherUHC
0312480001OtherPALMETTO GBA
B9760OtherMEDCOST
NC093KWOtherBCBS
P00249058OtherRAILROAD MEDICARE
P00249058OtherRAILROAD MEDICARE
0312480001OtherPALMETTO GBA
U93224Medicare UPIN