Provider Demographics
NPI:1881826378
Name:JONATHAN R RUSSELL, M.D., P.A.
Entity Type:Organization
Organization Name:JONATHAN R RUSSELL, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-440-4089
Mailing Address - Street 1:503 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-2625
Mailing Address - Country:US
Mailing Address - Phone:832-746-4301
Mailing Address - Fax:832-559-3718
Practice Address - Street 1:10130 LOUETTA RD
Practice Address - Street 2:STE G
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-2118
Practice Address - Country:US
Practice Address - Phone:281-440-4089
Practice Address - Fax:832-559-3718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0557174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143751902Medicaid
TXH35722Medicare UPIN
TX00145QMedicare PIN