Provider Demographics
NPI:1649513615
Name:RUSSELL, TROY MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:MATTHEW
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 1:9444 E 108TH AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80640-7578
Mailing Address - Country:US
Mailing Address - Phone:202-830-6096
Mailing Address - Fax:
Practice Address - Street 1:9444 E 108TH AVE APT 203
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80640-7578
Practice Address - Country:US
Practice Address - Phone:202-830-6096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139898207Q00000X, 207QB0002X
MA272232207Q00000X, 207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-139898OtherIL LIC
IL036139898Medicaid
IL036139898Medicaid