Provider Demographics
NPI:1588683064
Name:RUSSELL, KATHLEEN (OD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:295 BUCK RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:HOLLAND
Mailing Address - State:PA
Mailing Address - Zip Code:18966-1733
Mailing Address - Country:US
Mailing Address - Phone:215-953-1200
Mailing Address - Fax:215-953-1201
Practice Address - Street 1:295 BUCK RD
Practice Address - Street 2:SUITE 114
Practice Address - City:HOLLAND
Practice Address - State:PA
Practice Address - Zip Code:18966-1733
Practice Address - Country:US
Practice Address - Phone:215-953-1200
Practice Address - Fax:215-953-1201
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001346152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management