Healthcare Provider Details

I. General information

NPI: 1942309034
Provider Name (Legal Business Name): JEFFREY LYNN RUSSELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 34-A
WATONGA OK
73772-9706
US

IV. Provider business mailing address

2001 S COUNTRY CLUB RD APT. #701
EL RENO OK
73036-5689
US

V. Phone/Fax

Practice location:
  • Phone: 580-623-4991
  • Fax: 580-623-5490
Mailing address:
  • Phone: 580-623-4991
  • Fax: 580-623-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2966
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: