Provider Demographics
NPI:1801834189
Name:RUSSELL, RANDY HERSCHEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:HERSCHEL
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 1:1308 BELK BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5302
Mailing Address - Country:US
Mailing Address - Phone:662-234-6551
Mailing Address - Fax:662-234-0468
Practice Address - Street 1:1308 BELK BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5302
Practice Address - Country:US
Practice Address - Phone:662-234-6551
Practice Address - Fax:662-234-0468
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08418207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0011095Medicaid
MS0011095Medicaid