Provider Demographics
NPI:1043475353
Name:INGRAM, RUSSELL D (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:D
Last Name:INGRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7530 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-4921
Mailing Address - Country:US
Mailing Address - Phone:405-787-8550
Mailing Address - Fax:405-787-4982
Practice Address - Street 1:7530 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-4921
Practice Address - Country:US
Practice Address - Phone:405-787-8550
Practice Address - Fax:405-787-4982
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK26430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK26430OtherSTATE LICENSE