Healthcare Provider Details

I. General information

NPI: 1720080666
Provider Name (Legal Business Name): CHRISTINE L RUSSIAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 CENTRAL ST
LOWELL MA
01852-1927
US

IV. Provider business mailing address

41 LINCOLN ST
WINCHESTER MA
01890-2024
US

V. Phone/Fax

Practice location:
  • Phone: 978-458-4546
  • Fax: 978-934-9264
Mailing address:
  • Phone: 781-729-6464
  • Fax: 978-458-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3406
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: