MEDICARE: RUSSELL H VANNORMAN III M.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	207W00000X	Ophthalmology Physician	204870	LA
2	207WX0120X	Cornea and External Diseases Specialist Physician	204870	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4J088B236	OTHER	LA	MEDICARE

General Provider Information

NPI Number	:	1679576961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL H VANNORMAN III M.D.

Provider Business Mailing Address
First Line	:	1801 FAIRFIELD AVE STE 207
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-4460
Country	:	US
Telephone Number	:	318-703-5655
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 FAIRFIELD AVE STE 207
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-4460
Country	:	US
Telephone Number	:	318-703-5655
Fax Number	:	318-606-5470

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	04/06/2018

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