Healthcare Provider Details

I. General information

NPI: 1962408658
Provider Name (Legal Business Name): DUANE L. RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S 11TH AVE
LAUREL MS
39440-4312
US

IV. Provider business mailing address

117 S 11TH AVE
LAUREL MS
39440-4312
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-3033
  • Fax: 601-428-6561
Mailing address:
  • Phone: 601-425-3033
  • Fax: 601-428-6561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number017375
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: