Healthcare Provider Details

I. General information

NPI: 1205148707
Provider Name (Legal Business Name): JONATHON O RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7226 LEE DEFOREST DR STE 204
COLUMBIA MD
21046-3238
US

IV. Provider business mailing address

7226 LEE DEFOREST DR STE 204
COLUMBIA MD
21046-3238
US

V. Phone/Fax

Practice location:
  • Phone: 443-333-5233
  • Fax: 443-333-5232
Mailing address:
  • Phone: 443-333-5233
  • Fax: 443-333-5232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberD0079238
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberAC2895437L2
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: