Healthcare Provider Details

I. General information

NPI: 1053430744
Provider Name (Legal Business Name): RUSSELL BRUCE HUBBARD MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 HOTEL CIR S STE 310
SAN DIEGO CA
92108-3419
US

IV. Provider business mailing address

PO BOX 1770
LA MESA CA
91944-1770
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-8005
  • Fax: 619-297-1700
Mailing address:
  • Phone: 619-295-8005
  • Fax: 619-297-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL BRUCE HUBBARD
Title or Position: OWNER
Credential: M.D.
Phone: 619-295-8005