Healthcare Provider Details

I. General information

NPI: 1265492938
Provider Name (Legal Business Name): RUSSELL EMMETT DAVIS III OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 MEDICAL PARK DR
MELBOURNE FL
32901-3235
US

IV. Provider business mailing address

108 TEQUESTA HARBOR DR
MERRITT ISLAND FL
32952-7107
US

V. Phone/Fax

Practice location:
  • Phone: 321-728-7418
  • Fax: 321-728-7403
Mailing address:
  • Phone: 321-449-0894
  • Fax: 321-449-0894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT7148
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: