Provider Demographics
NPI:1609895069
Name:RUSS, DONALD J (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:RUSS
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:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-302-9300
Mailing Address - Fax:704-302-9301
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:SUITE 3100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4369
Practice Address - Country:US
Practice Address - Phone:704-302-9300
Practice Address - Fax:704-302-9301
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8974036Medicaid
SC193375Medicaid
NC74036OtherBCBS OF NC
NCNCH854AMedicare PIN
NC210088KMedicare PIN
NC74036OtherBCBS OF NC
NC210088JMedicare PIN
NC110229131Medicare PIN
NC8974036Medicaid