Provider Demographics
NPI:1720178445
Name:RUSSELL, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
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 1:5700 LAKE WORTH RD STE 204
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3213
Mailing Address - Country:US
Mailing Address - Phone:561-966-7707
Mailing Address - Fax:
Practice Address - Street 1:5317 ATLANTIC AVE STE 104
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8175
Practice Address - Country:US
Practice Address - Phone:561-496-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD30182207R00000X
MDD0030182207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
39949003OtherBCBS OF MD
MD369001600Medicaid
0012OtherBCBS OF DC
0943ER-399490-05OtherCAREFIRST BCBS OF MD
152XMedicare PIN
D73839Medicare UPIN
MD369001600Medicaid
M99950015Medicare PIN