Provider Demographics
NPI:1487850558
Name:VANDE VEGTE, RUSSELL ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ALLEN
Last Name:VANDE VEGTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2509 ARNOTT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1152
Mailing Address - Country:US
Mailing Address - Phone:619-276-7980
Mailing Address - Fax:
Practice Address - Street 1:4510 VIEWRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1637
Practice Address - Country:US
Practice Address - Phone:858-694-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140662251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic