Provider Demographics
NPI:1114924693
Name:RUSSO, ROBERT D (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4695 MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1802
Mailing Address - Country:US
Mailing Address - Phone:203-538-5233
Mailing Address - Fax:203-538-5246
Practice Address - Street 1:75 KINGS HIGHWAY CUTOFF
Practice Address - Street 2:SUITE 1A
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5340
Practice Address - Country:US
Practice Address - Phone:203-815-1877
Practice Address - Fax:203-538-5246
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2017-03-07
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Provider Licenses
StateLicense IDTaxonomies
CT0168052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001168053Medicaid
CT001168053Medicaid
300001886Medicare PIN