Healthcare Provider Details

I. General information

NPI: 1235175977
Provider Name (Legal Business Name): RUSSELL DENEA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 A1A S
SAINT AUGUSTINE FL
32080-6942
US

IV. Provider business mailing address

4102 A1A S
SAINT AUGUSTINE FL
32080-6942
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-1300
  • Fax: 904-471-1333
Mailing address:
  • Phone: 904-471-1300
  • Fax: 904-471-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number195944
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME121648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: