Provider Demographics
NPI:1265522528
Name:SANDBERG, RUSSELL LEONARD (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LEONARD
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:433 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1210
Mailing Address - Country:US
Mailing Address - Phone:415-456-1649
Mailing Address - Fax:415-456-1649
Practice Address - Street 1:1466 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2021
Practice Address - Country:US
Practice Address - Phone:415-457-3755
Practice Address - Fax:415-457-0849
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG26538207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G265381Medicaid
CAG26538Medicare UPIN