Provider Demographics
NPI:1932321700
Name:RUSSELL, DAVID STANTON (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:STANTON
Last Name:RUSSELL
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 1:2113 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-6622
Mailing Address - Country:US
Mailing Address - Phone:580-233-2136
Mailing Address - Fax:580-237-5965
Practice Address - Street 1:2113 WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-6622
Practice Address - Country:US
Practice Address - Phone:580-233-2136
Practice Address - Fax:580-237-5965
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK81352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD35228Medicare UPIN