Healthcare Provider Details

I. General information

NPI: 1487744330
Provider Name (Legal Business Name): ALBERT RUSSELL LA SPADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MANCHESTER AVE STE 110
ORANGE CA
92868-3214
US

IV. Provider business mailing address

200 S MANCHESTER AVE STE 300
ORANGE CA
92868-3219
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-2332
  • Fax:
Mailing address:
  • Phone: 714-456-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License NumberG88598
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG88598
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberG88598
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: