Provider Demographics
NPI:1528037892
Name:RUSSELL, SUDHA A (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1559
Mailing Address - Country:US
Mailing Address - Phone:661-635-3050
Mailing Address - Fax:661-326-1347
Practice Address - Street 1:1835 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-1404
Practice Address - Country:US
Practice Address - Phone:805-345-3701
Practice Address - Fax:805-345-3745
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54900207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10100OtherBCBS PROVIDER #
FL057297799Medicaid
FL10100OtherBCBS PROVIDER #