Provider Demographics
NPI:1114983442
Name:RUSSO, JOHN J (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 PANNICK DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08610-1129
Mailing Address - Country:US
Mailing Address - Phone:609-585-6967
Mailing Address - Fax:
Practice Address - Street 1:10 SCHALKS CROSSING RD
Practice Address - Street 2:
Practice Address - City:PLAINSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08536-1612
Practice Address - Country:US
Practice Address - Phone:609-275-8989
Practice Address - Fax:609-275-9327
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOAO 4698152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0641930001OtherMEDICARE NSC
NJ0641930001OtherMEDICARE NSC
1114983442Medicare PIN