Provider Demographics
NPI:1508840919
Name:RUSSELL, LAURA A (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1000
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:1050 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-491-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61396207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G613960Medicaid
CAE68867Medicare UPIN
CA00G613960Medicaid
CAWG61396BMedicare PIN