Provider Demographics
NPI:1447568597
Name:PACQUETTE, RUSSELL HERBERT (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:HERBERT
Last Name:PACQUETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 E. 65TH STREET
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-3555
Practice Address - Street 1:11251 FONDREN RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-5507
Practice Address - Country:US
Practice Address - Phone:281-707-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA79222207R00000X
TXU7131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301104108OtherSTATE LICENSE
GA003208359AMedicaid