Active NPI
John Douglas Russell, DDS
- Dentist
- Shasta Lake City, CA
National Provider Identifier
1902958077
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 20042
- Practice address
- 4178 Ashby Court
Shasta Lake City, CA 96019 - Phone
- (530) 275-2910
- Fax
- (530) 275-9335
- NPI assigned
- Jan 17, 2007
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 20042 | CA | Primary |
Addresses
Primary practice location
4178 Ashby Court
Shasta Lake City, CA 96019
Mailing address
4178 Ashby Court
Shasta Lake City, CA 96019
Phone (530) 275-2910
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| B2004201 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 20042 | CA | MD | Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168992000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1902958077",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4178 ASHBY COURT",
"city": "SHASTA LAKE CITY",
"state": "CA",
"postal_code": "96019",
"telephone_number": "530-275-2910",
"fax_number": "530-275-9335"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4178 ASHBY COURT",
"city": "SHASTA LAKE CITY",
"state": "CA",
"postal_code": "96019",
"telephone_number": "530-275-2910",
"fax_number": "530-275-9335"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSELL",
"first_name": "JOHN",
"middle_name": "DOUGLAS",
"name_prefix": "Mr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-01-17",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "20042",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "B2004201",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Shasta Lake City, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.