Healthcare Provider Details

I. General information

NPI: 1205986858
Provider Name (Legal Business Name): JENNIFER S RUSSELL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13005 US HIGHWAY 301 S
RIVERVIEW FL
33578-7439
US

IV. Provider business mailing address

2716 W VIRGINIA AVE
TAMPA FL
33607
US

V. Phone/Fax

Practice location:
  • Phone: 813-875-8032
  • Fax: 813-875-0227
Mailing address:
  • Phone: 813-875-8032
  • Fax: 813-875-0227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS9837
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: