Provider Demographics
NPI:1881686392
Name:PACKARD, RUSSELL C (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:C
Last Name:PACKARD
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 1:4000 S LOOP 256 STE A-E
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8467
Mailing Address - Country:US
Mailing Address - Phone:903-731-5372
Mailing Address - Fax:903-731-5130
Practice Address - Street 1:4659 FM 1990
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-1162
Practice Address - Country:US
Practice Address - Phone:903-213-2216
Practice Address - Fax:903-213-9233
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME307792084N0400X, 2084P0800X
TXL50822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1881686392OtherNPI
FL1881686392OtherNPI
TX105489202Medicaid
NM63976OtherPRESBYTERIAN COMMERCIAL
TXD53279Medicare UPIN
TX8D9581Medicare ID - Type Unspecified
TX84282ZMedicaid
TX120894100OtherFIRSTCARE COMMERCIAL
TX87834KMedicare ID - Type Unspecified
TX105489205Medicaid
TX8U1308OtherBC/BS
NM66381Medicaid
NMA385OtherTRIWEST
TX105489201Medicaid
TX88706SOtherBCBS
TX120894101Medicaid
NM63976Medicaid