Healthcare Provider Details

I. General information

NPI: 1033198510
Provider Name (Legal Business Name): ERIC BRIAN RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 DAVE WARD DR SUITE 202
CONWAY AR
72034-8686
US

IV. Provider business mailing address

2425 DAVE WARD DR SUITE 202
CONWAY AR
72034-8686
US

V. Phone/Fax

Practice location:
  • Phone: 501-328-5050
  • Fax:
Mailing address:
  • Phone: 501-328-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberE3133
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: