Provider Demographics
NPI:1578942918
Name:RUSSELL, CHRISTOPHER M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
Last Name:RUSSELL
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 1:1812 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1834
Mailing Address - Country:US
Mailing Address - Phone:407-897-3499
Mailing Address - Fax:407-896-9454
Practice Address - Street 1:1812 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1834
Practice Address - Country:US
Practice Address - Phone:407-897-3499
Practice Address - Fax:407-896-9454
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME141118208800000X
MI4301106752390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program