Provider Demographics
NPI:1902885742
Name:RUSSELL, DONALD L (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:RUSSELL
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 1:2600 6TH ST SW
Mailing Address - Street 2:SUITE A2-710
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1702
Mailing Address - Country:US
Mailing Address - Phone:330-454-8076
Mailing Address - Fax:330-454-3927
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-3207
Practice Address - Country:US
Practice Address - Phone:330-454-8076
Practice Address - Fax:330-454-3927
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-6531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0556483Medicaid
OH0556483Medicaid
OHRU0547396Medicare PIN