Provider Demographics
NPI:1629091517
Name:CRAIN, RUSSELL DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:DEAN
Last Name:CRAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11011 HEFNER POINTE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5054
Mailing Address - Country:US
Mailing Address - Phone:405-971-9393
Mailing Address - Fax:405-751-8894
Practice Address - Street 1:11011 HEFNER POINTE DR
Practice Address - Street 2:SUITE B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5005
Practice Address - Country:US
Practice Address - Phone:405-971-9393
Practice Address - Fax:405-751-8894
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14388207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100124610AMedicaid
OK800522114Medicare ID - Type Unspecified
OK100124610AMedicaid