Basic Information
| Provider Information | |||||||||
| NPI: | 1902216740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIBBY | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 VISION PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773843001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814043000 | ||||||||
| FaxNumber: | 9362736911 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 VISION PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773843001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814043000 | ||||||||
| FaxNumber: | 9362736911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2014 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208800000X | S5214 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1C5535 | 05 | TX | MEDICAID |