Provider Demographics
NPI:1821527292
Name:VAN MAELE, RUSSELL AARON (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:AARON
Last Name:VAN MAELE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 WELLINGTON WAY STE 330
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1331
Mailing Address - Country:US
Mailing Address - Phone:859-523-4375
Mailing Address - Fax:
Practice Address - Street 1:535 WELLINGTON WAY STE 330
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1331
Practice Address - Country:US
Practice Address - Phone:859-523-4375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04823207R00000X
MI5151012371390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program