Provider Demographics
NPI:1629041827
Name:PHILLIPS, RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:PHILLIPS
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 1:171 N DENTON TAP RD
Mailing Address - Street 2:#200
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2915
Mailing Address - Country:US
Mailing Address - Phone:972-745-4446
Mailing Address - Fax:972-745-2597
Practice Address - Street 1:171 N DENTON TAP RD
Practice Address - Street 2:#200
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2915
Practice Address - Country:US
Practice Address - Phone:972-745-4446
Practice Address - Fax:972-745-2597
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE89812Medicare UPIN
TX8782M7Medicare ID - Type Unspecified