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General NPI Number Information
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NPI Number | 1881826378
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Entity Type | Organization
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Legal Business Name | JONATHAN R RUSSELL, M.D., P.A.
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Dates
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Enumeration Date | 08/17/2009
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Last Update Date | 11/16/2011
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Provider Practice Location Address
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Address Line | 10130 LOUETTA RD STE G
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City | HOUSTON
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State | TX
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Zip | 77070-2118
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Country | US
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Telephone | 281-440-4089
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Fax | 832-559-3718
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Provider Business Mailing Address
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Address Line | 503 COLUMBIA ST
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City | HOUSTON
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State | TX
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Zip | 77007-2625
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Country | US
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Telephone | 832-746-4301
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Fax | 832-559-3718
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Authorized Official
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Title or Position | PRESIDENT/PHYSICIAN
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Name | MR. JONATHAN R RUSSELL
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Credential | M.D.
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Telephone | 281-440-4089
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | L0557
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License Number State | TX
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