Provider Demographics
NPI:1083612469
Name:RUSSO, GORDON J (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:J
Last Name:RUSSO
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 1:3725 LAKE MICHAEL CT
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-8326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 MEADOWCREST ST
Practice Address - Street 2:SUITE 160
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5255
Practice Address - Country:US
Practice Address - Phone:504-391-7620
Practice Address - Fax:504-391-7524
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015208207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1329495Medicaid
LA55856Medicare ID - Type Unspecified
LA1329495Medicaid