Provider Demographics
NPI:1902365083
Name:RUSSELL, REBECCA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 FOULK RD STE 100B
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-2764
Mailing Address - Country:US
Mailing Address - Phone:302-477-3300
Mailing Address - Fax:302-477-3311
Practice Address - Street 1:1401 FOULK RD STE 100B
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-2764
Practice Address - Country:US
Practice Address - Phone:302-477-3300
Practice Address - Fax:302-477-3311
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0024830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine