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General NPI Number Information
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NPI Number | 1922395722
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Entity Type | Individual
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Provider Name | DOROTHY MARQUITA YOLANDA RUSS M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/30/2011
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Last Update Date | 03/05/2019
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Provider Practice Location Address
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Address Line | 2 SHIRCLIFF WAY STE 900
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4753
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Country | US
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Telephone | 904-381-9651
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Fax | 904-389-9319
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Provider Business Mailing Address
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Address Line | 8390 CHAMPIONS GATE BLVD STE 215
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City | CHAMPIONS GATE
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State | FL
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Zip | 33896-8310
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Country | US
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Telephone | 321-401-1366
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME116132
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License Number State | FL
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