Provider Demographics
NPI:1639140791
Name:RUSSOM, JILL M (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:RUSSOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:305 EAST CENTER AVE.
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6331
Mailing Address - Country:US
Mailing Address - Phone:559-737-4700
Mailing Address - Fax:559-737-4782
Practice Address - Street 1:12586 AVENUE
Practice Address - Street 2:
Practice Address - City:OROSI
Practice Address - State:CA
Practice Address - Zip Code:93647-9454
Practice Address - Country:US
Practice Address - Phone:559-528-2804
Practice Address - Fax:559-528-7623
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA71632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH43415Medicare UPIN
CA00A716320Medicare ID - Type Unspecified