Provider Demographics
NPI:1376623066
Name:VANDENBELT, RUSSELL ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALBERT
Last Name:VANDENBELT
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 1:11201 SE 8TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6420
Mailing Address - Country:US
Mailing Address - Phone:425-454-0255
Mailing Address - Fax:425-454-3066
Practice Address - Street 1:11201 SE 8TH ST STE 105
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6420
Practice Address - Country:US
Practice Address - Phone:425-454-0255
Practice Address - Fax:425-454-3066
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000195322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA06168Medicare UPIN