Provider Demographics
NPI:1710369095
Name:CARLSTON, RUSSELL (DPM)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:CARLSTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 ST JOSEPH PKWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-8301
Mailing Address - Country:US
Mailing Address - Phone:713-756-8217
Mailing Address - Fax:
Practice Address - Street 1:516 W 14TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-1215
Practice Address - Country:US
Practice Address - Phone:308-995-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE369213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program