Provider Demographics
NPI:1598837163
Name:HOLMES, RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:HOLMES
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 1:3156 VISTA WAY
Mailing Address - Street 2:405
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3622
Mailing Address - Country:US
Mailing Address - Phone:760-439-6581
Mailing Address - Fax:
Practice Address - Street 1:3156 VISTA WAY
Practice Address - Street 2:405
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-3622
Practice Address - Country:US
Practice Address - Phone:760-439-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44968174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG44968NMedicaid
CA00G449680Medicare ID - Type Unspecified
CAWG44968NMedicaid