Provider Demographics
NPI:1184086936
Name:RUSSELL, DUVAL (LPTA)
Entity type:Individual
Prefix:
First Name:DUVAL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 RED BUG LAKE RD FL 32765
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7154
Mailing Address - Country:US
Mailing Address - Phone:407-971-2774
Mailing Address - Fax:
Practice Address - Street 1:7400 RED BUG LAKE RD FL 32765
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7154
Practice Address - Country:US
Practice Address - Phone:407-971-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26037225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant