Provider Demographics
NPI:1245258235
Name:RUSS, KENNETH CARL (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CARL
Last Name:RUSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 S FARRELL DR
Mailing Address - Street 2:SUITE C106
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-7992
Mailing Address - Country:US
Mailing Address - Phone:760-416-6773
Mailing Address - Fax:760-416-6843
Practice Address - Street 1:13525 CIELO AZUL WAY
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-6235
Practice Address - Country:US
Practice Address - Phone:760-329-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE62869Medicare UPIN
CA00A482240Medicare ID - Type Unspecified