Provider Demographics
NPI:1942309034
Name:RUSSELL, JEFFREY LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S COUNTRY CLUB RD
Mailing Address - Street 2:APT. #701
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-5689
Mailing Address - Country:US
Mailing Address - Phone:580-623-4991
Mailing Address - Fax:580-623-5490
Practice Address - Street 1:RR 1 BOX 34-A
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-9706
Practice Address - Country:US
Practice Address - Phone:580-623-4991
Practice Address - Fax:580-623-5490
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2966213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK9102966Medicaid
OK9102966Medicaid
OK8HE367Medicare ID - Type UnspecifiedEL RENO INDIAN HLTH CTR
OK8HE365Medicare Oscar/Certification
OK8HE366Medicare ID - Type UnspecifiedWATONGA INDIAN HLTH CTR