Healthcare Provider Details

I. General information

NPI: 1750303038
Provider Name (Legal Business Name): DON R RUSSELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 S MERIDIAN SUITE A
PUYALLUP WA
98371-7531
US

IV. Provider business mailing address

1910 S MERIDIAN SUITE A
PUYALLUP WA
98371-7531
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-2303
  • Fax: 253-848-8956
Mailing address:
  • Phone: 253-848-2303
  • Fax: 253-848-8956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOPOOOOO811
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: