Provider Demographics
NPI:1013601186
Name:RUSSELL, TESS (OD)
Entity Type:Individual
Prefix:
First Name:TESS
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HIGHLAND AVE # 345
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1516
Mailing Address - Country:US
Mailing Address - Phone:810-404-2962
Mailing Address - Fax:
Practice Address - Street 1:5203 MONROE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3139
Practice Address - Country:US
Practice Address - Phone:567-455-9232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist