1487643441 NPI number — DR. CLARENCE HENRY RUSSELL III O.D.

Table of content: DR. CLARENCE HENRY RUSSELL III O.D. (NPI 1487643441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487643441 NPI number — DR. CLARENCE HENRY RUSSELL III O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
CLARENCE
Provider Middle Name:
HENRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487643441
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3466 LITHIA PINECREST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALRICO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33594-6301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-657-3937
Provider Business Mailing Address Fax Number:
813-661-9009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3466 LITHIA PINECREST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALRICO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33594-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-657-3937
Provider Business Practice Location Address Fax Number:
813-661-9009
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  OPC2807 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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