Provider Demographics
NPI:1639385644
Name:HUNTER, RUSSELL LANNY (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LANNY
Last Name:HUNTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R.
Other - Middle Name:LANNY
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10730
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0730
Mailing Address - Country:US
Mailing Address - Phone:928-776-0325
Mailing Address - Fax:928-776-0405
Practice Address - Street 1:830 AINSWORTH DRIVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1614
Practice Address - Country:US
Practice Address - Phone:928-776-0325
Practice Address - Fax:928-776-0405
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ6167207N00000X
AZ6167207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ206781Medicaid
AZ6167OtherARIZ LIC
AZ6167OtherARIZ LIC
D37058Medicare UPIN
AZD37058Medicare UPIN
AZ126670Medicare PIN