Provider Demographics
NPI:1073581237
Name:RUSSELL, SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41120 WASHINGTON ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-9596
Mailing Address - Country:US
Mailing Address - Phone:760-360-3193
Mailing Address - Fax:760-360-3194
Practice Address - Street 1:41120 WASHINGTON ST STE 201
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-9596
Practice Address - Country:US
Practice Address - Phone:760-360-3193
Practice Address - Fax:760-360-3194
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12138207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110000981Medicare ID - Type Unspecified
G33600Medicare UPIN