MEDICARE: RUSSELL DENEA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	195944	NY
2	2084P0800X	Psychiatry Physician	ME121648	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	960396	OTHER	NY	MVP
2	B56MB	OTHER	FL	FLORIDA BLUE

General Provider Information

NPI Number	:	1235175977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL DENEA MD

Provider Business Mailing Address
First Line	:	4102 A1A S
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-6942
Country	:	US
Telephone Number	:	904-471-1300
Fax Number	:	904-471-1333

Provider Business Practice Location Address
First Line	:	4102 A1A S
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-6942
Country	:	US
Telephone Number	:	904-471-1300
Fax Number	:	904-471-1333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	03/17/2018

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Directions to “ RUSSELL DENEA MD” Practice Location

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