Provider Demographics
NPI:1609947449
Name:RUSSELL, MARIE ANN (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ANN
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 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1511
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:150 VALPREDA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2973
Practice Address - Country:US
Practice Address - Phone:760-736-8689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28355207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ634685Medicaid
AZAZ0713260OtherBCBSAZ
AZ634685Medicaid
AZ030078Medicare Oscar/Certification
AZAZ0713260OtherBCBSAZ