Provider Demographics
NPI:1114903218
Name:RUSSO, JOSEPH A (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:364 MAINE MALL RD STE F128
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3206
Mailing Address - Country:US
Mailing Address - Phone:207-383-3456
Mailing Address - Fax:207-383-3409
Practice Address - Street 1:364 MAINE MALL RD STE F128
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3206
Practice Address - Country:US
Practice Address - Phone:207-383-3456
Practice Address - Fax:207-383-3409
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT1037152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0700177Medicaid
MA0700177Medicaid
MAU82902Medicare UPIN