Provider Demographics
NPI:1568541365
Name:RUSSO, CARLA RAE (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RAE
Last Name:RUSSO
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 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5687
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60136154207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0062RUOtherREGENCE
WA1568541365Medicaid
WA0261505OtherL&I AND CRIME VICTIMS
WA0261505OtherL&I AND CRIME VICTIMS