Provider Demographics
NPI:1790783439
Name:RUSSELL, R. DENIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:DENIS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7506
Mailing Address - Country:US
Mailing Address - Phone:714-979-0313
Mailing Address - Fax:714-979-0340
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-979-0313
Practice Address - Fax:714-979-0340
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2008-02-15
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CAE1393213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT19100Medicare UPIN
CAE1393Medicare PIN