Provider Demographics
NPI:1720130305
Name:RUSSELL, KIMBERLY TANIS (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:TANIS
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 1:36065 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5060
Mailing Address - Country:US
Mailing Address - Phone:254-288-8932
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTE FE AVE
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-5044
Practice Address - Country:US
Practice Address - Phone:254-288-8932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069021L207Q00000X
TXN0422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine