Provider Demographics
NPI:1982047635
Name:RUSSELL, TARA ANASTASIA (MD, MPH)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANASTASIA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 214
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3955
Practice Address - Country:US
Practice Address - Phone:310-794-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA136212208C00000X, 208600000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA136212OtherCALIFORNIA STATE MEDICAL LICENSE
FR5294866OtherDEA