Provider Demographics
NPI:1396856290
Name:DUNNUM, RUSSELL PAUL (MD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:PAUL
Last Name:DUNNUM
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 1:4510 EXECUTIVE DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3021
Mailing Address - Country:US
Mailing Address - Phone:858-457-4717
Mailing Address - Fax:858-457-0470
Practice Address - Street 1:4510 EXECUTIVE DR
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3021
Practice Address - Country:US
Practice Address - Phone:858-457-4717
Practice Address - Fax:858-457-0470
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG549990Medicaid
CAB57973Medicare UPIN
CABDG5499Medicare ID - Type Unspecified