Provider Demographics
NPI:1457374019
Name:WORRALL, RUSSELL STABLER (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:STABLER
Last Name:WORRALL
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 1:333 S AUBURN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLFAX
Mailing Address - State:CA
Mailing Address - Zip Code:95713-9778
Mailing Address - Country:US
Mailing Address - Phone:530-346-2269
Mailing Address - Fax:530-346-2593
Practice Address - Street 1:333 S AUBURN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:COLFAX
Practice Address - State:CA
Practice Address - Zip Code:95713-9778
Practice Address - Country:US
Practice Address - Phone:530-346-2269
Practice Address - Fax:530-346-2593
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6581T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0065810Medicare ID - Type Unspecified
CASD0065812Medicare PIN
CAT10364Medicare UPIN
CA0236660002Medicare NSC