Healthcare Provider Details

I. General information

NPI: 1487643441
Provider Name (Legal Business Name): CLARENCE HENRY RUSSELL III O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 LITHIA PINECREST RD
VALRICO FL
33594-6301
US

IV. Provider business mailing address

3466 LITHIA PINECREST RD
VALRICO FL
33594-6301
US

V. Phone/Fax

Practice location:
  • Phone: 813-657-3937
  • Fax: 813-661-9009
Mailing address:
  • Phone: 813-657-3937
  • Fax: 813-661-9009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC2807
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: