Healthcare Provider Details

I. General information

NPI: 1356678155
Provider Name (Legal Business Name): ROBYN A RUSSELL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 N 6TH AVE
WAUCHULA FL
33873-2002
US

IV. Provider business mailing address

21 S LAKE AVE
AVON PARK FL
33825-3901
US

V. Phone/Fax

Practice location:
  • Phone: 863-773-3322
  • Fax: 863-773-6458
Mailing address:
  • Phone: 863-385-7070
  • Fax: 888-971-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPC4379
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC4379
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4379
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: