Provider Demographics
NPI:1588634026
Name:RUSSELL, JAMES A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
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 1:3902 KILLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KILLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05751
Mailing Address - Country:US
Mailing Address - Phone:802-422-6125
Mailing Address - Fax:802-422-6798
Practice Address - Street 1:3902 KILLINGTON RD
Practice Address - Street 2:
Practice Address - City:KILLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05751
Practice Address - Country:US
Practice Address - Phone:802-422-6125
Practice Address - Fax:802-422-6798
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT6866174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT5565Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NO