Provider Demographics
NPI:1063728657
Name:RUSS, ADAM JOHN (OD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JOHN
Last Name:RUSS
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 S GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-7308
Mailing Address - Country:US
Mailing Address - Phone:812-479-5208
Mailing Address - Fax:812-471-0486
Practice Address - Street 1:562 S GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-7308
Practice Address - Country:US
Practice Address - Phone:812-479-5208
Practice Address - Fax:812-471-0486
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003640A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201046070Medicaid
IN201046070Medicaid
INP01028586Medicare PIN