Healthcare Provider Details

I. General information

NPI: 1568469211
Provider Name (Legal Business Name): RUSSELL EUGENE MAYO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E 6TH ST
TEXARKANA AR
71854-5207
US

IV. Provider business mailing address

300 E 6TH ST
TEXARKANA AR
71854-5207
US

V. Phone/Fax

Practice location:
  • Phone: 870-779-6000
  • Fax: 870-779-6093
Mailing address:
  • Phone: 870-779-6000
  • Fax: 870-779-6093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC6443
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG9874
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: