Healthcare Provider Details

I. General information

NPI: 1508920588
Provider Name (Legal Business Name): RUSSELL LAURENCE TUVERSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 FARMINGTON AVE
BRISTOL CT
06010
US

IV. Provider business mailing address

975 FARMINGTON AVE
BRISTOL CT
06010
US

V. Phone/Fax

Practice location:
  • Phone: 860-589-0114
  • Fax: 860-589-1936
Mailing address:
  • Phone: 860-589-0114
  • Fax: 860-589-1936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number021636
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: