Provider Demographics
NPI:1801030564
Name:RUSSELL, TRAVIS CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:CHARLES
Last Name:RUSSELL
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:PSC 80 BOX 16805
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0071
Mailing Address - Country:US
Mailing Address - Phone:801-678-1416
Mailing Address - Fax:
Practice Address - Street 1:18 MDG, UNIT 5142
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368
Practice Address - Country:US
Practice Address - Phone:315-630-4229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-25
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine