Provider Demographics
NPI:1013068576
Name:NG, RUSSELL BRIAN (OD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:BRIAN
Last Name:NG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 ELKHORN BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95842-2526
Mailing Address - Country:US
Mailing Address - Phone:916-331-1222
Mailing Address - Fax:
Practice Address - Street 1:5311 ELKHORN BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95842-2526
Practice Address - Country:US
Practice Address - Phone:916-331-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10517T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0105170Medicaid
CAU64580Medicare UPIN
CASD0105173Medicare PIN