Basic Information
| Provider Information | |||||||||
| NPI: | 1760596415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | FRANKLIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7909 FREDERICKSBURG RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106144544 | ||||||||
| FaxNumber: | 2105825522 | ||||||||
| Practice Location | |||||||||
| Address1: | 12709 TOEPPERWEIN RD | ||||||||
| Address2: | SUITE #206 | ||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105648000 | ||||||||
| FaxNumber: | 2105907945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D8420 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 036247702 | 05 | TX | MEDICAID |