Provider Demographics
NPI:1881698538
Name:SKINNER, RUSSELL B (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:B
Last Name:SKINNER
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 1:5148 VILLAGE CREEK DR
Mailing Address - Street 2:STE 300
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5064
Mailing Address - Country:US
Mailing Address - Phone:469-661-1100
Mailing Address - Fax:
Practice Address - Street 1:5148 VILLAGE CREEK DR
Practice Address - Street 2:STE 300
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5064
Practice Address - Country:US
Practice Address - Phone:469-661-1100
Practice Address - Fax:469-661-1100
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130931208Medicaid
TX110216569OtherRAILROAD MCR #
TX8A3122OtherBCBS IND #
TXK5697OtherMEDICAL LICENSE
TX8X8470OtherBCBS WOUND CARE
TX130931201Medicaid
TX130931201Medicaid
TX339279YXL1Medicare PIN