Provider Demographics
NPI:1376582981
Name:RUSSIAN, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:RUSSIAN
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 1:12728 19TH AVE. SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6647
Mailing Address - Country:US
Mailing Address - Phone:425-252-1116
Mailing Address - Fax:425-252-1118
Practice Address - Street 1:12728 19TH AVE. SE
Practice Address - Street 2:SUITE 200
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6647
Practice Address - Country:US
Practice Address - Phone:425-252-1116
Practice Address - Fax:425-252-1118
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031772207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0124070OtherLABOR AND INDUSTRY
WAMD00031772OtherSTATE LICENSE NUMBER
WA290010791OtherRAILROAD MEDICARE
WA8232043Medicaid
WAMD00031772OtherSTATE LICENSE NUMBER
WAG8877575Medicare PIN
WA0124070OtherLABOR AND INDUSTRY