Individual
EDGAR RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
6276 RIVER CREST DR, RIVERSIDE, CA 92507-0754
(951) 413-0964
(951) 653-5161
Mailing address
1413 CALLE DE ORO, SAN DIMAS, CA 91773-4015
(909) 592-4566
(909) 576-6904
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
Primary
20A6100
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0086790
—
CA
Enumeration date
07/24/2006
Last updated
07/09/2007
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