Healthcare Provider Details

I. General information

NPI: 1912085697
Provider Name (Legal Business Name): ANTHONY W. RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N ASHWOOD AVE
VENTURA CA
93003
US

IV. Provider business mailing address

5855 OLIVAS PARK DR
VENTURA CA
93003-7672
US

V. Phone/Fax

Practice location:
  • Phone: 805-658-5800
  • Fax: 805-642-1928
Mailing address:
  • Phone: 805-667-2801
  • Fax: 805-667-2865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA85115
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: