Healthcare Provider Details

I. General information

NPI: 1639140791
Provider Name (Legal Business Name): JILL M. RUSSOM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12586 AVENUE
OROSI CA
93647-9454
US

IV. Provider business mailing address

305 EAST CENTER AVE.
VISALIA CA
93291-6331
US

V. Phone/Fax

Practice location:
  • Phone: 559-528-2804
  • Fax: 559-528-7623
Mailing address:
  • Phone: 559-737-4700
  • Fax: 559-737-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA71632
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: