Provider Demographics
NPI:1851386379
Name:HART, RUSSELL W (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:W
Last Name:HART
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4030
Mailing Address - Country:US
Mailing Address - Phone:785-240-5517
Mailing Address - Fax:
Practice Address - Street 1:8072 NORMANDY DR
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-7069
Practice Address - Country:US
Practice Address - Phone:785-240-5516
Practice Address - Fax:785-239-4065
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1396-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS651142OtherBCBS
KS100219860EMedicaid
KSU43890Medicare UPIN