Provider Demographics
NPI:1740591478
Name:RUSSI, MELVIN F JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:F
Last Name:RUSSI
Suffix:JR
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 1:12200 COLINA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5299
Mailing Address - Country:US
Mailing Address - Phone:650-941-8212
Mailing Address - Fax:
Practice Address - Street 1:12200 COLINA DR
Practice Address - Street 2:
Practice Address - City:LOS ALTOS HILLS
Practice Address - State:CA
Practice Address - Zip Code:94024-5299
Practice Address - Country:US
Practice Address - Phone:650-941-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGFE11171208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGFE11171OtherMEDICAL BOARD OF CALIFORNIA CERTIFICATE
CAA38256Medicare UPIN