Provider Demographics
NPI:1578530408
Name:WEISTER, RUSSELL JAMES (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JAMES
Last Name:WEISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E 19TH AVE
Mailing Address - Street 2:SUITE 3050
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1216
Mailing Address - Country:US
Mailing Address - Phone:303-320-1227
Mailing Address - Fax:303-320-1235
Practice Address - Street 1:1601 E 19TH AVE
Practice Address - Street 2:SUITE 3050
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1216
Practice Address - Country:US
Practice Address - Phone:303-320-1227
Practice Address - Fax:303-320-1235
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO24118207V00000X
FLME92330207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01241181Medicaid
D24392Medicare UPIN
CO01241181Medicaid