Provider Demographics
NPI:1376644799
Name:DAVIS, RUSSELL C (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2 BON AIR RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1142
Mailing Address - Country:US
Mailing Address - Phone:415-927-3336
Mailing Address - Fax:415-927-3170
Practice Address - Street 1:2 BON AIR RD STE 150
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1142
Practice Address - Country:US
Practice Address - Phone:415-927-3336
Practice Address - Fax:415-927-3170
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2804213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E28040Medicaid
CA000E28041Medicare ID - Type Unspecified
CA000E28040Medicaid