Provider Demographics
NPI:1760479570
Name:RUSSELL, ROY E JR (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:E
Last Name:RUSSELL
Suffix:JR
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:PO BOX 402139
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2319
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:5111 ROGERS AVE
Practice Address - Street 2:STE 40M
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2047
Practice Address - Country:US
Practice Address - Phone:479-709-7440
Practice Address - Fax:479-709-7441
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC7967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100100550AMedicaid
AR121868001Medicaid
ARF34510Medicare UPIN
OK100100550AMedicaid