Provider Demographics
NPI:1699739961
Name:RUSSACK, VALENTINA (MD)
Entity type:Individual
Prefix:
First Name:VALENTINA
Middle Name:
Last Name:RUSSACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 FROST ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2701
Mailing Address - Country:US
Mailing Address - Phone:858-939-3660
Mailing Address - Fax:858-939-3647
Practice Address - Street 1:7901 FROST ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2701
Practice Address - Country:US
Practice Address - Phone:858-939-3660
Practice Address - Fax:858-939-3660
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58905207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE78326Medicare UPIN
CAWG58905KMedicare ID - Type UnspecifiedPPIN