Healthcare Provider Details

I. General information

NPI: 1265522528
Provider Name (Legal Business Name): RUSSELL LEONARD SANDBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1466 LINCOLN AVE
SAN RAFAEL CA
94901-2021
US

IV. Provider business mailing address

433 THE ALAMEDA
SAN ANSELMO CA
94960-1210
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-3755
  • Fax: 415-457-0849
Mailing address:
  • Phone: 415-456-1649
  • Fax: 415-456-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberG26538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: