1760596415 NPI number — DR. LEWIS FRANKLIN RUSSELL M.D.

Table of content: DR. LEWIS FRANKLIN RUSSELL M.D. (NPI 1760596415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760596415 NPI number — DR. LEWIS FRANKLIN RUSSELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
LEWIS
Provider Middle Name:
FRANKLIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1760596415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7909 FREDERICKSBURG RD
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-614-4544
Provider Business Mailing Address Fax Number:
210-582-5522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12709 TOEPPERWEIN RD
Provider Second Line Business Practice Location Address:
SUITE #206
Provider Business Practice Location Address City Name:
LIVE OAK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78233-3258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-564-8000
Provider Business Practice Location Address Fax Number:
210-590-7945
Provider Enumeration Date:
08/19/2006

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: 208800000X , with the licence number:  D8420 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036247702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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