Healthcare Provider Details

I. General information

NPI: 1205468634
Provider Name (Legal Business Name): RUSSELL DE JONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
SAN ANTONIO TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number33801
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA207835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: