Healthcare Provider Details

I. General information

NPI: 1366948473
Provider Name (Legal Business Name): ROBERT SAGE RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

1000 NE 13TH ST # 1G
OKLAHOMA CITY OK
73104-5040
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4742
  • Fax: 405-271-2619
Mailing address:
  • Phone: 405-271-3445
  • Fax: 856-326-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number37087
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37087
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: