Provider Demographics
NPI:1538391032
Name:RUSSELL, CHRISTEN MICHELE (OD)
Entity type:Individual
Prefix:DR
First Name:CHRISTEN
Middle Name:MICHELE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7051 SOUTHPOINT PKWY S FL 3R
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8713
Mailing Address - Country:US
Mailing Address - Phone:904-398-2720
Mailing Address - Fax:904-483-5650
Practice Address - Street 1:7051 SOUTHPOINT PKWY S FL 3R
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8713
Practice Address - Country:US
Practice Address - Phone:904-398-2720
Practice Address - Fax:904-483-5650
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT002558OtherGEORGIA LICENSE
FLOPC4460OtherFLORIDA LICENSE
GAMR2054930OtherDEA
FLOPC4460OtherFLORIDA LICENSE