Provider Demographics
NPI:1780620856
Name:NELSON, RUSSELL WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WILLIAM
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4679
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91359-1679
Mailing Address - Country:US
Mailing Address - Phone:805-379-2322
Mailing Address - Fax:978-244-8700
Practice Address - Street 1:250 LOMBARD ST STE 1
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8208
Practice Address - Country:US
Practice Address - Phone:805-370-0748
Practice Address - Fax:978-244-8700
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA47320Medicare UPIN
CAWG38011EMedicare PIN