Provider Demographics
NPI:1346256369
Name:CONSIGLIO, RUSSELL E (PA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:CONSIGLIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 58TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3160 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5219
Practice Address - Country:US
Practice Address - Phone:916-733-5336
Practice Address - Fax:916-733-5385
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10894207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4663625OtherAETNA
CA6753334OtherCIGNA
CA461130OtherINTERPLAN
CA90078280OtherPACIFICARE
CAPA10894Medicaid
CA10899748OtherGREAT WEST
CAPA10894OtherBLUE CROSS
CA90078280OtherPACIFICARE
CAPA10894Medicaid