Provider Demographics
NPI:1205996576
Name:LIBBY, RUSSELL CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:CLARK
Last Name:LIBBY
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 1:1347 LANCIA DR
Mailing Address - Street 2:
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-2203
Mailing Address - Country:US
Mailing Address - Phone:703-827-4011
Mailing Address - Fax:
Practice Address - Street 1:3020 HAMAKER CT
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2238
Practice Address - Country:US
Practice Address - Phone:703-573-2432
Practice Address - Fax:703-280-9350
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033734208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics