Healthcare Provider Details

I. General information

NPI: 1790707156
Provider Name (Legal Business Name): EDGAR RUSSELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6276 RIVER CREST DR
RIVERSIDE CA
92507-0754
US

IV. Provider business mailing address

1413 CALLE DE ORO
SAN DIMAS CA
91773-4015
US

V. Phone/Fax

Practice location:
  • Phone: 951-413-0964
  • Fax: 951-653-5161
Mailing address:
  • Phone: 909-592-4566
  • Fax: 909-576-6904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A6100
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: