Provider Demographics
NPI:1184709636
Name:HELTSLEY, RUSSELL KING III (OD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:KING
Last Name:HELTSLEY
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 SCOTTSVILLE RD
Mailing Address - Street 2:SUITE #114
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-4457
Mailing Address - Country:US
Mailing Address - Phone:270-846-2500
Mailing Address - Fax:270-846-0608
Practice Address - Street 1:2425 SCOTTSVILLE RD
Practice Address - Street 2:SUITE #114
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4457
Practice Address - Country:US
Practice Address - Phone:270-846-2500
Practice Address - Fax:270-846-0608
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1216 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77012169Medicaid
KY9355201Medicare ID - Type Unspecified
3918290001Medicare NSC
KY77012169Medicaid