Provider Demographics
NPI:1750333704
Name:RUSS, JOHN KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KEVIN
Last Name:RUSS
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 1:4228 HOUMA BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-3000
Mailing Address - Country:US
Mailing Address - Phone:504-454-7878
Mailing Address - Fax:504-883-3775
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:STE 200
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-454-7878
Practice Address - Fax:504-883-3775
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD015424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1329274Medicaid
LA1329274Medicaid
LA55827Medicare ID - Type Unspecified