Healthcare Provider Details

I. General information

NPI: 1033373451
Provider Name (Legal Business Name): DAVID JOSEPH RUSSELL MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BRYANT WILLIAMS DR
KLAMATH FALLS OR
97601-1120
US

IV. Provider business mailing address

PO BOX 5109
KLAMATH FALLS OR
97601-0119
US

V. Phone/Fax

Practice location:
  • Phone: 541-274-2894
  • Fax: 541-274-3392
Mailing address:
  • Phone: 541-882-1540
  • Fax: 541-882-2583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD28531
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD28531
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier024212
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DAVID J RUSSELL
Title or Position: OWNER
Credential: MD
Phone: 541-274-2894