Provider Demographics
NPI:1639137540
Name:RUSSELL, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SEYED-MEHRDAD
Other - Middle Name:
Other - Last Name:ALERASSOUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12223 HIGHLAND AVE # 106-536
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2574
Mailing Address - Country:US
Mailing Address - Phone:760-241-3547
Mailing Address - Fax:760-241-3562
Practice Address - Street 1:13024 HESPERIA RD STE 103
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8303
Practice Address - Country:US
Practice Address - Phone:760-241-3547
Practice Address - Fax:760-241-3562
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA144701207RC0000X, 207RI0011X
NY229134390200000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I09007Medicare UPIN