Provider Demographics
NPI:1184950313
Name:RUSSELL, KATHRYN JOY (MD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:JOY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 VENETIAN COURT SUITE 1
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109
Mailing Address - Country:US
Mailing Address - Phone:239-596-9337
Mailing Address - Fax:239-596-9466
Practice Address - Street 1:2235 VENETIAN COURT SUITE 1
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109
Practice Address - Country:US
Practice Address - Phone:619-543-6268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL115577207NP0225X, 207NS0135X, 207NI0002X, 207ND0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1558371195Medicare UPIN