Individual
RUSS TODD NELSON
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
LPT
Contact information
Practice address
4303 TEXAS BLVD, STE 8, TEXARKANA, TX 75503-3097
(903) 793-1797
(903) 793-2105
Mailing address
4303 TEXAS BLVD, STE 8, TEXARKANA, TX 75503-3097
(903) 793-1797
(903) 793-2105
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
1090942
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1090942
TX LICENSE
TX
01
—
86940T
BCBS ID NUMBER
TX
01
—
99451
AR BCBS NUMBER
AR
Enumeration date
09/14/2005
Last updated
07/08/2007
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