Provider Demographics
NPI:1871230706
Name:REEVES, RUSSELL ROBERT
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ROBERT
Last Name:REEVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CAMINO DE VIDA STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2267
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:877-651-0289
Practice Address - Street 1:117 CAMINO DE VIDA STE 300
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2267
Practice Address - Country:US
Practice Address - Phone:575-472-4311
Practice Address - Fax:877-651-0289
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2025-1037207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine