Basic Information
| Provider Information | |||||||||
| NPI: | 1326038662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2445 | ||||||||
| Address2: | |||||||||
| City: | SKYLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287762445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752644 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 MCDOWELL ST | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288014104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282553749 | ||||||||
| FaxNumber: | 8282549925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 38683 | NC | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 2146366A | 01 | NC | MEDICARE PTAN | OTHER | 8974027 | 05 | NC | MEDICAID |