Provider Demographics
NPI:1982632857
Name:RUSSELL, CARL L (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 CROSS TIMBERS RD STE 116
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2740
Mailing Address - Country:US
Mailing Address - Phone:800-958-3527
Mailing Address - Fax:817-490-1107
Practice Address - Street 1:2550 CROSS TIMBERS RD STE 116
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2740
Practice Address - Country:US
Practice Address - Phone:800-958-3527
Practice Address - Fax:817-490-1107
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL3808207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150821001Medicaid
TX150821003Medicaid
TX150821002Medicaid
TX150821002Medicaid
TXA52998Medicare UPIN
TX150821003Medicaid
TX8K2645Medicare PIN