Basic Information
| Provider Information | |||||||||
| NPI: | 1538391032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | CHRISTEN | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7051 SOUTHPOINT PKWY S FL 3R | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043982720 | ||||||||
| FaxNumber: | 9044835650 | ||||||||
| Practice Location | |||||||||
| Address1: | 7051 SOUTHPOINT PKWY S FL 3R | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043982720 | ||||||||
| FaxNumber: | 9044835650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2009 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC 4460 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | OPT002558 | 01 | GA | GEORGIA LICENSE | OTHER | OPC4460 | 01 | FL | FLORIDA LICENSE | OTHER | MR2054930 | 01 | GA | DEA | OTHER |