Healthcare Provider Details

I. General information

NPI: 1073755971
Provider Name (Legal Business Name): JAMES MILLER RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 PACIFIC AVE APT 81
SAN FRANCISCO CA
94115-1426
US

IV. Provider business mailing address

2299 PACIFIC AVE APT 81
SAN FRANCISCO CA
94115-1426
US

V. Phone/Fax

Practice location:
  • Phone: 317-719-6174
  • Fax:
Mailing address:
  • Phone: 317-719-6174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG-196097
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD179941
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: