Basic Information
| Provider Information | |||||||||
| NPI: | 1699735829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | BELINDA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5187 US ROUTE 60 EAST | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046918800 | ||||||||
| FaxNumber: | 3043020221 | ||||||||
| Practice Location | |||||||||
| Address1: | 5187 US ROUTE 60 EAST | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046918800 | ||||||||
| FaxNumber: | 3043020221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1025-OD | WV | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2601625 | 05 | OH | MEDICAID | 3810003533 | 05 | WV | MEDICAID | 77001378 | 05 | KY | MEDICAID |