Provider Demographics
NPI:1831180900
Name:RUSSELL, RYAN D (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-6895
Mailing Address - Country:US
Mailing Address - Phone:662-869-1779
Mailing Address - Fax:
Practice Address - Street 1:610 BRUNSON DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4947
Practice Address - Country:US
Practice Address - Phone:662-844-7211
Practice Address - Fax:662-844-7574
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00001062Medicaid
MSU96380Medicare UPIN
MS410000291Medicare ID - Type Unspecified