Provider Demographics
NPI:1598772923
Name:RUSSELL, RICHARD SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SCOTT
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R.
Other - Middle Name:SCOTT
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:18 JAYSON AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4238
Mailing Address - Country:US
Mailing Address - Phone:516-773-8002
Mailing Address - Fax:516-773-8002
Practice Address - Street 1:18 JAYSON AVE
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4238
Practice Address - Country:US
Practice Address - Phone:516-773-8002
Practice Address - Fax:516-773-8002
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172558207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10811759OtherCAQH
NY0F718OtherEMPIRE BLUE SHIELD
NY0F718OtherEMPIRE BLUE SHIELD
NY10811759OtherCAQH