Healthcare Provider Details

I. General information

NPI: 1598343915
Provider Name (Legal Business Name): RUSLAN DMITRIEVICH NAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 METRO PKWY. BLDG. 3, STE 1
FORT MYERS FL
33966
US

IV. Provider business mailing address

11215 METRO PKWY. BLDG. 3, STE 1
FORT MYERS FL
33966
US

V. Phone/Fax

Practice location:
  • Phone: 239-208-2212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number34.018762
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDR.0078147
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberW8891
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: