Provider Demographics
NPI:1922173822
Name:RUSSELL, DEREK DUNCAN (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:DUNCAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 MCCOMAS WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3986
Mailing Address - Country:US
Mailing Address - Phone:757-427-7690
Mailing Address - Fax:757-427-7692
Practice Address - Street 1:2125 MCCOMAS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3986
Practice Address - Country:US
Practice Address - Phone:757-427-7690
Practice Address - Fax:757-427-7692
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555920111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA175426OtherBLUE CROSS BLUE SHIELD
VA175426OtherBLUE CROSS BLUE SHIELD
VA00V075D21Medicare ID - Type UnspecifiedMEDICARE