Healthcare Provider Details

I. General information

NPI: 1780722868
Provider Name (Legal Business Name): KEVIN L. RUSSELL MD, MTM&H
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

1615 E 7TH ST
OKMULGEE OK
74447-4813
US

V. Phone/Fax

Practice location:
  • Phone: 760-522-8973
  • Fax:
Mailing address:
  • Phone: 760-522-8973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number20269
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: