Provider Demographics
NPI:1003893330
Name:DIPONIO, RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DIPONIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 W BRISTOL RD STE 150
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3161
Mailing Address - Country:US
Mailing Address - Phone:810-230-9500
Mailing Address - Fax:810-230-0169
Practice Address - Street 1:4444 W BRISTOL RD STE 150
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-230-9500
Practice Address - Fax:810-230-0169
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7300207R00000X
MI4301405760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4374949Medicaid
AR5AN64C474OtherMEDICARE
AR191500001Medicaid
AR191500001Medicaid
MIE16087Medicare UPIN