Provider Demographics
NPI:1700177391
Name:PELLA, RUSSELL D (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:D
Last Name:PELLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S VANDALIA AVE
Mailing Address - Street 2:APT. 4G
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-4038
Mailing Address - Country:US
Mailing Address - Phone:210-309-5124
Mailing Address - Fax:
Practice Address - Street 1:5213 S VANDALIA AVE
Practice Address - Street 2:APT. 4G
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-4038
Practice Address - Country:US
Practice Address - Phone:210-309-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34782103G00000X
OK1248103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284979601Medicaid
TXTXB135826Medicare PIN