Provider Demographics
NPI:1811346414
Name:SOARES, REBECCA RUSS (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:RUSS
Last Name:SOARES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3640 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1139
Mailing Address - Country:US
Mailing Address - Phone:413-732-2333
Mailing Address - Fax:413-732-8065
Practice Address - Street 1:3640 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1139
Practice Address - Country:US
Practice Address - Phone:413-732-2333
Practice Address - Fax:413-732-8065
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD469774207W00000X
MA292078207WX0107X
PAMT212460390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist