Provider Demographics
NPI:1982819074
Name:GEOFFREY, RUSSELL JAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JAN
Last Name:GEOFFREY
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 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-7267
Mailing Address - Fax:541-682-3707
Practice Address - Street 1:2411 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5824
Practice Address - Country:US
Practice Address - Phone:541-682-7267
Practice Address - Fax:541-682-3707
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1625752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500658448Medicaid
E38726Medicare UPIN