Provider Demographics
NPI:1902872476
Name:RUSSELL, GORDON D (OD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5327
Mailing Address - Country:US
Mailing Address - Phone:505-325-7070
Mailing Address - Fax:505-326-2756
Practice Address - Street 1:3450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5327
Practice Address - Country:US
Practice Address - Phone:505-325-7070
Practice Address - Fax:505-325-5812
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMU97709Medicare UPIN
NMNMB2057Medicare PIN
NMNM072Medicare PIN