Provider Demographics
NPI:1679576961
Name:VANNORMAN, RUSSELL H III (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:H
Last Name:VANNORMAN
Suffix:III
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 1:1801 FAIRFIELD AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4460
Mailing Address - Country:US
Mailing Address - Phone:318-703-5655
Mailing Address - Fax:
Practice Address - Street 1:1801 FAIRFIELD AVE STE 207
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4460
Practice Address - Country:US
Practice Address - Phone:318-703-5655
Practice Address - Fax:318-606-5470
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204870207W00000X, 207WX0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4J088B236OtherMEDICARE
LA4J088B236OtherMEDICARE