MEDICARE: DR. RUSSELL STABLER WORRALL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6581T	CA

General Provider Information

NPI Number	:	1457374019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL STABLER WORRALL O.D.

Provider Business Mailing Address
First Line	:	333 S AUBURN ST
Second Line	:	SUITE 1
City	:	COLFAX
State	:	CA
Zip	:	95713-9778
Country	:	US
Telephone Number	:	530-346-2269
Fax Number	:	530-346-2593

Provider Business Practice Location Address
First Line	:	333 S AUBURN ST
Second Line	:	SUITE 1
City	:	COLFAX
State	:	CA
Zip	:	95713-9778
Country	:	US
Telephone Number	:	530-346-2269
Fax Number	:	530-346-2593

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2008

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