Healthcare Provider Details

I. General information

NPI: 1790959625
Provider Name (Legal Business Name): MELISSA L RUSSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7237
  • Fax: 757-668-8215
Mailing address:
  • Phone: 757-668-7237
  • Fax: 757-668-8215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number0101252201
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: