Provider Demographics
NPI:1245286921
Name:RUSSELL, RENEE JEAN (MD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:JEAN
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 1:1110 NEO LOOP
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-6046
Mailing Address - Country:US
Mailing Address - Phone:918-786-3100
Mailing Address - Fax:918-786-3108
Practice Address - Street 1:1110 NEO LOOP
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-6046
Practice Address - Country:US
Practice Address - Phone:918-786-3100
Practice Address - Fax:918-786-3108
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100017290DMedicaid
OK100017290EMedicaid
OKH73424Medicare UPIN
OK900522115Medicare ID - Type UnspecifiedGRP#
OK100017290DMedicaid