Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 5101015814 | MI |
NPI | 1316162704 |
---|---|
Provider Name | Dr. Russell Weldon Mayes |
First Address | Twin Falls, ID 83303-0587 |
Second Address | Twin Falls, ID 83301-3382 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2007 |
Last Update Date | 29/12/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
808041500 | (05) | ID |
P00654616 | MCRR (01) | ID |