Provider Demographics
NPI:1568813863
Name:RUSSELL, AARON JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:AARON
Middle Name:JACOB
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-273-3376
Mailing Address - Fax:888-682-0525
Practice Address - Street 1:969 N MASON RD
Practice Address - Street 2:DIV IM DERMATOLOGY, STE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6282
Practice Address - Country:US
Practice Address - Phone:314-273-3376
Practice Address - Fax:888-682-0525
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2021011092207ZD0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200061535Medicaid