Provider Demographics
NPI:1861463341
Name:MCCAULLEY, RUSSELL L (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:L
Last Name:MCCAULLEY
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 1:2601 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-4253
Mailing Address - Country:US
Mailing Address - Phone:620-792-2020
Mailing Address - Fax:
Practice Address - Street 1:2601 10TH ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4253
Practice Address - Country:US
Practice Address - Phone:620-792-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1198-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100218010AMedicaid
KS410020390OtherPALMENTTO GBA RR MEDICARE
KS1861463341OtherNPI
KS100218010AMedicaid
KS005342Medicare PIN