Provider Demographics
NPI:1376644799
Name:DAVIS, RUSSELL C (DPM)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S ELISEO DR STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2105
Mailing Address - Country:US
Mailing Address - Phone:628-253-5164
Mailing Address - Fax:415-927-3170
Practice Address - Street 1:1000 S ELISEO DR STE 102
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2105
Practice Address - Country:US
Practice Address - Phone:628-253-5164
Practice Address - Fax:415-927-3170
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2025-07-14
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