Provider Demographics
NPI:1801845862
Name:RUSSELL, DAVID PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
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 1:249 MIDWAY MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1693
Mailing Address - Country:US
Mailing Address - Phone:423-968-3033
Mailing Address - Fax:423-968-3789
Practice Address - Street 1:249 MIDWAY MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1693
Practice Address - Country:US
Practice Address - Phone:423-968-3033
Practice Address - Fax:423-968-3789
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19081174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006241069Medicaid
TN3052410Medicare ID - Type Unspecified
E45844Medicare UPIN