Provider Demographics
NPI:1356337422
Name:PHELPS, RUSSELL T (DO)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:T
Last Name:PHELPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:R.
Other - Middle Name:TOM
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:337-521-9100
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4600 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6902
Practice Address - Country:US
Practice Address - Phone:337-521-9100
Practice Address - Fax:337-470-2019
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8421207V00000X
LA303334207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1481122Medicaid
TX102762501Medicaid
8581J2Medicare ID - Type Unspecified
LA1481122Medicaid