Provider Demographics
NPI:1699772210
Name:GOLLARD, RUSSELL PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:PATRICK
Last Name:GOLLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3175 SAINT ROSE PKWY FL 2
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3506
Practice Address - Country:US
Practice Address - Phone:702-724-8787
Practice Address - Fax:702-878-3078
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7818207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019902Medicaid
NV830006195OtherRAILROAD MEDICARE
AZ121745Medicaid
G30004Medicare UPIN
NV32552Medicare PIN