Provider Demographics
NPI:1780174581
Name:RUSSELL, MARINA TAWFIK (MD)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:TAWFIK
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 1:801 HAZELWEST DR
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1754
Mailing Address - Country:US
Mailing Address - Phone:314-919-2700
Mailing Address - Fax:
Practice Address - Street 1:801 HAZELWEST DR
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1754
Practice Address - Country:US
Practice Address - Phone:314-919-2700
Practice Address - Fax:314-919-2777
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021002109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program