1528037892 NPI number — SUDHA A RUSSELL MD

Table of content: SUDHA A RUSSELL MD (NPI 1528037892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528037892 NPI number — SUDHA A RUSSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
SUDHA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528037892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93302-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-635-3050
Provider Business Mailing Address Fax Number:
661-326-1347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1835 N BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MARIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93454-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-345-3701
Provider Business Practice Location Address Fax Number:
805-345-3745
Provider Enumeration Date:
03/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PP0204X , with the licence number:  G54900 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: G54900 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10100 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 057297799 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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