Provider Demographics
NPI:1790707156
Name:RUSSELL, EDGAR (DO)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
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 1:1413 CALLE DE ORO
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4015
Mailing Address - Country:US
Mailing Address - Phone:909-592-4566
Mailing Address - Fax:909-576-6904
Practice Address - Street 1:6276 RIVER CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0754
Practice Address - Country:US
Practice Address - Phone:951-413-0964
Practice Address - Fax:951-653-5161
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6100207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086790Medicaid
CAGR0086790Medicaid
CAZZZ37592ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER