Provider Demographics
NPI:1205927829
Name:RUSSELL, KENNETH L (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:RUSSELL
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:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:TX
Mailing Address - Zip Code:76442-0554
Mailing Address - Country:US
Mailing Address - Phone:325-356-7051
Mailing Address - Fax:
Practice Address - Street 1:514 S BONHAM ST
Practice Address - Street 2:
Practice Address - City:MEXIA
Practice Address - State:TX
Practice Address - Zip Code:76667-3600
Practice Address - Country:US
Practice Address - Phone:325-356-7051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6568207R00000X, 207RC0200X, 207RG0100X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140407162Medicaid
TX86618GOtherBCBSTX
TXH6568OtherSTATE MEDICAL LICENSE
TX140407162Medicaid
TX86618GOtherBCBSTX
TX88162NMedicare PIN