Provider Demographics
NPI:1770539967
Name:RUSSELL, THOMAS JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JEFFREY
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 1:3535 TRAVIS ST STE 170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-1480
Mailing Address - Country:US
Mailing Address - Phone:214-522-2661
Mailing Address - Fax:214-522-5469
Practice Address - Street 1:3535 TRAVIS ST STE 170
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-1480
Practice Address - Country:US
Practice Address - Phone:214-522-2661
Practice Address - Fax:214-522-5469
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2746207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123810705Medicaid
TX8475M0OtherBLUE CROSS BLUE SHIELD
TX180041912OtherRAILROAD MEDICARE
TX123810705Medicaid
TX180041912OtherRAILROAD MEDICARE