Provider Demographics
NPI:1578971396
Name:LILES, RUSSELL ISAAC (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ISAAC
Last Name:LILES
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 1:4415 LOOP 322
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-8056
Mailing Address - Country:US
Mailing Address - Phone:325-370-5513
Mailing Address - Fax:
Practice Address - Street 1:4415 LOOP 322
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79602-8056
Practice Address - Country:US
Practice Address - Phone:325-603-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2817152W00000X
TX8529TG152W00000X
TX8529T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist