Provider Demographics
NPI:1073041299
Name:JEFFERSON, RUSSELL WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WAYNE
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-4303
Mailing Address - Country:US
Mailing Address - Phone:580-819-0082
Mailing Address - Fax:
Practice Address - Street 1:501 S 11TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-4303
Practice Address - Country:US
Practice Address - Phone:580-819-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK6428208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program