Provider Demographics
NPI:1346069101
Name:ALTON, RUSSELL D
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:D
Last Name:ALTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32155 CORTE CARMELA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4303
Mailing Address - Country:US
Mailing Address - Phone:858-229-3959
Mailing Address - Fax:
Practice Address - Street 1:16766 BERNARDO CENTER DR, SAN DIEGO, CA 92128
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2546
Practice Address - Country:US
Practice Address - Phone:858-229-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health