Provider Demographics
NPI:1679792675
Name:RUSSELL, RICHARD A (LD)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-1523
Mailing Address - Country:US
Mailing Address - Phone:330-337-9794
Mailing Address - Fax:
Practice Address - Street 1:1995 E STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2423
Practice Address - Country:US
Practice Address - Phone:330-332-7664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD4685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRUMT71361Medicare ID - Type UnspecifiedMEDICARE PART B