Provider Demographics
NPI:1134112261
Name:SMITH, RUSSELL BURTON (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:BURTON
Last Name:SMITH
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 1:3901 UNIVERSITY BLVD S STE 112
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4312
Mailing Address - Country:US
Mailing Address - Phone:904-486-5466
Mailing Address - Fax:
Practice Address - Street 1:3901 UNIVERSITY BLVD S STE 112
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4312
Practice Address - Country:US
Practice Address - Phone:904-486-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME134346207YX0007X, 207Y00000X
NE24197207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1134112261Medicaid
IA0212142Medicaid
NE47078557504Medicaid
IA19770OtherWELLMARK BCBS
NE10025044400Medicaid
H20445Medicare UPIN
NE47078557504Medicaid