Healthcare Provider Details

I. General information

NPI: 1760475354
Provider Name (Legal Business Name): RUSSELL DODSON P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34975 N NORTH VALLEY PKWY SUITE 100
PHOENIX AZ
85086-4028
US

IV. Provider business mailing address

2500 W UTOPIA RD STE. 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 623-295-4820
  • Fax: 623-295-4830
Mailing address:
  • Phone: 602-214-6148
  • Fax: 602-214-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1015
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: