Provider Demographics
NPI:1194939447
Name:RUSSELL, JASON LUTHER (DO)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:LUTHER
Last Name:RUSSELL
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 1:332 CONGRESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:332 CONGRESS PARK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4133
Practice Address - Country:US
Practice Address - Phone:937-312-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-009466207P00000X, 207PT0002X
MI5101027902207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2935042Medicaid