Provider Demographics
NPI:1023022696
Name:NILES, RUSSELL E (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:NILES
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 Q ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-7058
Practice Address - Country:US
Practice Address - Phone:916-733-5336
Practice Address - Fax:916-733-5385
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32453207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1211321OtherGREAT WEST
CA4054751OtherAETNA
CAMCMG170800OtherWESTERN HEALTH ADVANTAGE
CA216368OtherUNITED HEALTHCARE
CA4364920OtherCIGNA
CA90018849OtherPACIFICARE
CA000810354304OtherPHCS
CA14028OtherINTERPLAN
CA012413OtherHEALTH NET
CA4812OtherFIRST HEALTH
CAG62453OtherBLUE CROSS
CA00G324530Medicaid
CA216368OtherUNITED HEALTHCARE
CA00G324531Medicare ID - Type Unspecified