1750303038 NPI number — DON R RUSSELL D.O.

Table of content: DON R RUSSELL D.O. (NPI 1750303038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750303038 NPI number — DON R RUSSELL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
DON
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1750303038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 S MERIDIAN
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-7531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-848-2303
Provider Business Mailing Address Fax Number:
253-848-8956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 S MERIDIAN
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98371-7531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-848-2303
Provider Business Practice Location Address Fax Number:
253-848-8956
Provider Enumeration Date:
07/24/2006

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: 208000000X , with the licence number:  OPOOOOO811 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1819200 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com