Provider Demographics
NPI:1760440630
Name:WEINTRAUB, RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:WEINTRAUB
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 1:5248 RED CEDAR DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4522
Mailing Address - Country:US
Mailing Address - Phone:239-936-7171
Mailing Address - Fax:239-936-7455
Practice Address - Street 1:5248 RED CEDAR DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4522
Practice Address - Country:US
Practice Address - Phone:239-936-7171
Practice Address - Fax:239-936-7455
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61320Medicare UPIN
FLE2527YMedicare ID - Type Unspecified