Provider Demographics
NPI:1316321565
Name:FRITZ, RUSSELL JR (LO)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:FRITZ
Suffix:JR
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 WHITNEY AVE.
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3504
Mailing Address - Country:US
Mailing Address - Phone:203-248-8224
Mailing Address - Fax:203-248-8628
Practice Address - Street 1:2313 WHITNEY AVE.
Practice Address - Street 2:SUITE 1D
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3504
Practice Address - Country:US
Practice Address - Phone:203-248-8224
Practice Address - Fax:203-248-8628
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000687156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician