MEDICARE: DAVID L. RUSSELL O.D.

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	152W00000X	Optometrist	1264-2	KS
2	152W00000X	Optometrist	1264-3	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578564522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID L. RUSSELL O.D.

Provider Business Mailing Address
First Line	:	1218 NORTH 79TH STREET
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66112-3308
Country	:	US
Telephone Number	:	913-788-3234
Fax Number	:

Provider Business Practice Location Address
First Line	:	1218 NORTH 79TH STREET
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66112-3308
Country	:	US
Telephone Number	:	913-788-3234
Fax Number	:

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	11/05/2011

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Directions to “ DAVID L. RUSSELL O.D.” Practice Location

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