Provider Demographics
NPI:1619948445
Name:SPADARO, RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:SPADARO
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 1:2125 E THOUSAND OAKS BLVD # B-1
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2942
Mailing Address - Country:US
Mailing Address - Phone:805-493-1964
Mailing Address - Fax:805-241-5382
Practice Address - Street 1:2125 E THOUSAND OAKS BLVD # B-1
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2942
Practice Address - Country:US
Practice Address - Phone:805-493-1964
Practice Address - Fax:805-492-0614
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55882208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics