Provider Demographics
NPI:1508255498
Name:RUSSAK, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:RUSSAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N COLLEGE PARK DR
Mailing Address - Street 2:UNIT #S33
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14748 HARTSOOK ST
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-309-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist