Individual
TARA ANASTASIA RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD, MPH
Contact information
Practice address
200 UCLA MEDICAL PLZ STE 214, LOS ANGELES, CA 90095-3955
(310) 794-7788
Mailing address
5767 W CENTURY BLVD STE 400, LOS ANGELES, CA 90045-5631
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
A136212
CA
208C00000X
Colon & Rectal Surgery Physician
A136212
CA
390200000X
Student in an Organized Health Care Education/Training Program
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A136212
CALIFORNIA STATE MEDICAL LICENSE
CA
Enumeration date
04/12/2013
Last updated
03/07/2023
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