Provider Demographics
NPI:1679598718
Name:RUSSELL, PEGGY M (DO)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 LAVACA ST
Mailing Address - Street 2:110-320
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-2172
Mailing Address - Country:US
Mailing Address - Phone:512-477-4088
Mailing Address - Fax:
Practice Address - Street 1:1108 LAVACA ST
Practice Address - Street 2:110-320
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2172
Practice Address - Country:US
Practice Address - Phone:512-477-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4461207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097796902Medicaid
TX110180474OtherMEDICARE RAILROAD
TX82020JOtherBCBS TEXAS
TX82020JMedicare ID - Type Unspecified
TX110180474OtherMEDICARE RAILROAD