Provider Demographics
NPI:1982145694
Name:RUSSELL, DYLAN (MD)
Entity type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:
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 1:1 JARRETT WHITE RD
Mailing Address - Street 2:TRIPLER ARMY MEDICAL CENTER
Mailing Address - City:TRIPLER ARMY MEDICAL CENTER
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH)
Practice Address - Street 2:UNIT 15245
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5245
Practice Address - Country:US
Practice Address - Phone:316-737-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-20545208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN