Provider Demographics
NPI:1578603494
Name:RUSSELL, JEFFREY DAVID (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 N PERKINS RD
Mailing Address - Street 2:APT # N 165
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-2962
Mailing Address - Country:US
Mailing Address - Phone:405-612-3921
Mailing Address - Fax:
Practice Address - Street 1:302 N MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7611
Practice Address - Country:US
Practice Address - Phone:918-245-2790
Practice Address - Fax:918-245-8436
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3284111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00318794Medicare ID - Type Unspecified
OKU60453Medicare UPIN