Basic Information
| Provider Information | |||||||||
| NPI: | 1922395722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSS | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | MARQUITA YOLANDA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8390 CHAMPIONS GATE BLVD STE 215 | ||||||||
| Address2: | |||||||||
| City: | CHAMPIONS GATE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338968310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214011366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 SHIRCLIFF WAY STE 900 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043819651 | ||||||||
| FaxNumber: | 9043899319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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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 | 207Q00000X | ME116132 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014862700 | 05 | FL | MEDICAID |