Healthcare Provider Details

I. General information

NPI: 1770565087
Provider Name (Legal Business Name): TIMOTHY PAUL RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 45011 BLDG 704, ATTN: MCJA-QM USA MEDDAC-JAPAN
APO AP
96338-5011
US

IV. Provider business mailing address

UNIT 45013 BOX 2884
APO AP
96338-5013
US

V. Phone/Fax

Practice location:
  • Phone: 011813117
  • Fax: 4127
Mailing address:
  • Phone: 011813117
  • Fax: 4127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21584-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: