Healthcare Provider Details

I. General information

NPI: 1548604895
Provider Name (Legal Business Name): BIANCA ELIZABETH RUSSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLAZA STE 256
LOS ANGELES CA
90095
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6581
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA154948
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberA154948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: