Provider Demographics
NPI:1023033081
Name:RUSSO, JENNEFER ALLYN (MD)
Entity Type:Individual
Prefix:
First Name:JENNEFER
Middle Name:ALLYN
Last Name:RUSSO
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 1:300 HALKET ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-3108
Mailing Address - Country:US
Mailing Address - Phone:412-641-3464
Mailing Address - Fax:412-641-1133
Practice Address - Street 1:700 S. TUSTIN STREET
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866
Practice Address - Country:US
Practice Address - Phone:714-633-6373
Practice Address - Fax:714-532-2522
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD439233207VG0400X
CAA82067207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology