Provider Demographics
NPI:1639173263
Name:PUTNAM, RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:PUTNAM
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 1:12554 RIATA VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6431
Mailing Address - Country:US
Mailing Address - Phone:512-795-5100
Mailing Address - Fax:512-795-5122
Practice Address - Street 1:12554 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6431
Practice Address - Country:US
Practice Address - Phone:512-795-5100
Practice Address - Fax:512-795-5122
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK03642085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141288404Medicaid
300133594OtherRRMCARE
TX141288408OtherCSHCN2
300133592OtherRRMCARE2
TX141288403Medicaid
TX141288406OtherCSHCN1
TX141288408OtherCSHCN2
300133592OtherRRMCARE2
TX141288403Medicaid