Provider Demographics
NPI:1629151402
Name:MACDONALD, RUSSELL MARTIN (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MARTIN
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 N DIVISION
Mailing Address - Street 2:105
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218
Mailing Address - Country:US
Mailing Address - Phone:509-466-1117
Mailing Address - Fax:509-464-0578
Practice Address - Street 1:12310 N DIVISION
Practice Address - Street 2:105
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218
Practice Address - Country:US
Practice Address - Phone:509-466-1117
Practice Address - Fax:509-464-0578
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH33968111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2024917Medicaid
WAAB21055Medicare ID - Type Unspecified
WA2024917Medicaid