Provider Demographics
NPI:1528610425
Name:RUSSELL, NICHOLAS
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DVM
Mailing Address - Street 1:2967 N MOORPARK RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4573
Mailing Address - Country:US
Mailing Address - Phone:805-492-2436
Mailing Address - Fax:
Practice Address - Street 1:2967 N MOORPARK RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4573
Practice Address - Country:US
Practice Address - Phone:805-492-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17490207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17490OtherDVM LICENSE