Healthcare Provider Details

I. General information

NPI: 1134821523
Provider Name (Legal Business Name): JOHN RUSSELL MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S ORANGE AVE
NEWARK NJ
07103-2757
US

IV. Provider business mailing address

185 S ORANGE AVE
NEWARK NJ
07103-2757
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-2229
  • Fax:
Mailing address:
  • Phone: 973-972-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD.MD.70168010
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: