Provider Demographics
NPI:1194446625
Name:RUSSELL, JOSEPH DANIEL (DPT)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DANIEL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9912 HAROLD BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7659
Mailing Address - Country:US
Mailing Address - Phone:813-610-3618
Mailing Address - Fax:
Practice Address - Street 1:912 AMERICAN EAGLE BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5228
Practice Address - Country:US
Practice Address - Phone:813-633-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist