Provider Demographics
NPI:1831166404
Name:CALDWELL, RUSSELL B (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:B
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1810 116TH AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3058
Mailing Address - Country:US
Mailing Address - Phone:425-455-2275
Mailing Address - Fax:425-455-1511
Practice Address - Street 1:1810 116TH AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3058
Practice Address - Country:US
Practice Address - Phone:425-455-2275
Practice Address - Fax:425-455-1511
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00015594207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA04196Medicare UPIN
WAGAB29472Medicare PIN