Provider Demographics
NPI:1851395529
Name:EYRE, RUSSELL WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WARREN
Last Name:EYRE
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 1:486 W 800 N
Mailing Address - Street 2:STE 201
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3728
Mailing Address - Country:US
Mailing Address - Phone:801-431-0300
Mailing Address - Fax:801-431-0312
Practice Address - Street 1:486 W 800 N
Practice Address - Street 2:STE 201
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3728
Practice Address - Country:US
Practice Address - Phone:801-431-0300
Practice Address - Fax:801-431-0312
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT174191-1205207N00000X, 207NI0002X, 207NS0135X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC63352Medicare UPIN