Provider Demographics
NPI:1821157983
Name:RUSSELL, MICHAEL J (PHD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 F ST #76
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616
Mailing Address - Country:US
Mailing Address - Phone:530-668-8988
Mailing Address - Fax:530-668-1229
Practice Address - Street 1:2025 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-973-6847
Practice Address - Fax:916-973-5611
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL116520Medicare ID - Type Unspecified