Healthcare Provider Details

I. General information

NPI: 1912049487
Provider Name (Legal Business Name): RICKY RUSSELL, M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 603
JACKSON MS
39202-1651
US

IV. Provider business mailing address

501 MARSHALL ST SUITE 603
JACKSON MS
39202-1651
US

V. Phone/Fax

Practice location:
  • Phone: 601-985-9120
  • Fax: 601-985-9122
Mailing address:
  • Phone: 601-985-9120
  • Fax: 601-985-9122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICKY GORDON RUSSELL
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 601-985-9120