Provider Demographics
NPI:1124236153
Name:GOLD, RUSSELL STUART (PHD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:STUART
Last Name:GOLD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 4TH AVE
Mailing Address - Street 2:SUITE 615
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-574-1694
Mailing Address - Fax:619-574-1649
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 615
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-574-1694
Practice Address - Fax:619-574-1649
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6175103TC0700X, 103TF0000X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP6175Medicare ID - Type Unspecified