Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | E3133 | AR |
NPI | 1033198510 |
---|---|
Provider Name | Dr. Eric Brian Russell |
First Address | Conway, AR 72034-8686 |
Second Address | Conway, AR 72034-8686 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2006 |
Last Update Date | 09/11/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
150036001 | (05) | AR |
H78127 | (02) | AR |