Provider Demographics
NPI:1588603708
Name:RUSSELL, BRANDON (DO)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-2015
Mailing Address - Country:US
Mailing Address - Phone:260-665-2141
Mailing Address - Fax:
Practice Address - Street 1:3640 NEW VISION DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1717
Practice Address - Country:US
Practice Address - Phone:260-482-4440
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003088207P00000X
OH34C.000055207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200825030Medicaid
IN178650AAAMedicare PIN
H93536Medicare UPIN
IN200825030Medicaid
IN047840038Medicare PIN