Provider Demographics
NPI:1720256407
Name:R. DENIS RUSSELL, D.P.M., INC.
Entity Type:Organization
Organization Name:R. DENIS RUSSELL, D.P.M., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:DENIS
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:714-979-0313
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7506
Mailing Address - Country:US
Mailing Address - Phone:714-979-0313
Mailing Address - Fax:714-979-0340
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-979-0313
Practice Address - Fax:714-979-0340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1393332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0397240001Medicare NSC