Healthcare Provider Details

I. General information

NPI: 1902830037
Provider Name (Legal Business Name): DEBORA J RUSSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E. NIZHONI BLVD BOX 1337
GALLUP NM
87301-1337
US

IV. Provider business mailing address

516 E. NIZHONI BLVD BOX 1337
GALLUP NM
87301-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1294
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number99-292
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: