Provider Demographics
NPI:1922395722
Name:RUSS, DOROTHY MARQUITA YOLANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:MARQUITA YOLANDA
Last Name:RUSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:321-401-1366
Mailing Address - Fax:
Practice Address - Street 1:2 SHIRCLIFF WAY STE 900
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4753
Practice Address - Country:US
Practice Address - Phone:904-381-9651
Practice Address - Fax:904-389-9319
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014862700Medicaid