Provider Demographics
NPI:1740233162
Name:RUSSELL, DAVID LEE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:RUSSELL
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:7 DEYE LN
Practice Address - Street 2:
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245-8578
Practice Address - Country:US
Practice Address - Phone:360-376-2561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8379844Medicaid
WA1740233162Medicaid
WA8800948Medicare ID - Type Unspecified
WA1740233162Medicaid