Provider Demographics
NPI:1053430744
Name:RUSSELL BRUCE HUBBARD MD INC
Entity type:Organization
Organization Name:RUSSELL BRUCE HUBBARD MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-295-8005
Mailing Address - Street 1:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:619-295-8005
Mailing Address - Fax:619-297-1700
Practice Address - Street 1:1565 HOTEL CIR S STE 310
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3419
Practice Address - Country:US
Practice Address - Phone:619-295-8005
Practice Address - Fax:619-297-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA125585700OtherOWCPACS (DEPT. LABOR WC)
CAG25680OtherMEDICAL LICENSE #
CA00G256800OtherMEDI-CAL
CA33-0317526OtherTAX ID #
CAAH8472071OtherDEA #
235666587OtherSOC. SEC. #
CAG25680OtherMEDICAL LICENSE #
CAAH8472071OtherDEA #