Provider Demographics
NPI:1124351937
Name:RUSSELL, JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1774 WINDSORBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-4831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2478 BURNSED BLVD # 466-A
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-2702
Practice Address - Country:US
Practice Address - Phone:352-399-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4461152W00000X
GAOPT2551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist