Provider Demographics
NPI:1396968566
Name:CHAMBLESS, RUSSELL (OD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:CHAMBLESS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3353 MERCER UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204
Mailing Address - Country:US
Mailing Address - Phone:478-745-1515
Mailing Address - Fax:
Practice Address - Street 1:3353 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-5082
Practice Address - Country:US
Practice Address - Phone:478-745-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU29629Medicare UPIN