Healthcare Provider Details

I. General information

NPI: 1245971209
Provider Name (Legal Business Name): RUSSOM DESTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 HOYT AVE
EVERETT WA
98201-4918
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-261-4076
  • Fax: 425-261-4078
Mailing address:
  • Phone: 206-860-5414
  • Fax: 206-720-8462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61579314
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: