Provider Demographics
NPI:1568469211
Name:MAYO, RUSSELL EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EUGENE
Last Name:MAYO
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 1:300 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5207
Mailing Address - Country:US
Mailing Address - Phone:870-779-6000
Mailing Address - Fax:870-779-6093
Practice Address - Street 1:300 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5207
Practice Address - Country:US
Practice Address - Phone:870-779-6000
Practice Address - Fax:870-779-6093
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6443207Q00000X
TXG9874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137635206Medicaid
AR106188001Medicaid
AR53407Medicare ID - Type Unspecified
AR106188001Medicaid