Provider Demographics
NPI:1699529354
Name:RUSSELL, JUSTIN D
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 ROTHBURY DR
Mailing Address - Street 2:
Mailing Address - City:BELLE ISLE
Mailing Address - State:FL
Mailing Address - Zip Code:32812-2213
Mailing Address - Country:US
Mailing Address - Phone:407-902-1988
Mailing Address - Fax:
Practice Address - Street 1:3714 ROTHBURY DR
Practice Address - Street 2:
Practice Address - City:BELLE ISLE
Practice Address - State:FL
Practice Address - Zip Code:32812-2213
Practice Address - Country:US
Practice Address - Phone:407-902-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer