Provider Demographics
NPI:1659635134
Name:RUSSELL, DAVID JULIUS (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JULIUS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
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 1090
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1090
Mailing Address - Country:US
Mailing Address - Phone:209-334-1800
Mailing Address - Fax:
Practice Address - Street 1:1617 N CALIFORNIA ST
Practice Address - Street 2:STE. 2F
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6117
Practice Address - Country:US
Practice Address - Phone:209-466-8546
Practice Address - Fax:209-466-3335
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14817207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology