Provider Demographics
NPI:1821103854
Name:HISSCOCK, RUSSELL G (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:G
Last Name:HISSCOCK
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 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-834-7930
Mailing Address - Fax:760-834-7931
Practice Address - Street 1:4791 E PALM CANYON DR STE 100
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-5232
Practice Address - Country:US
Practice Address - Phone:760-834-7930
Practice Address - Fax:760-834-7931
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4374207Q00000X
WAOP60690694207Q00000X
CA20A10268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA363180OtherSTATE L&I
AZ109455Medicaid
AZ109455Medicaid