Provider Demographics
NPI:1134294259
Name:RUSSO, SIMONE FRANK
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:FRANK
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 SABADO ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4125
Mailing Address - Country:US
Mailing Address - Phone:702-792-4077
Mailing Address - Fax:702-991-8044
Practice Address - Street 1:2900 E DESERT INN RD
Practice Address - Street 2:SUITE 108
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3619
Practice Address - Country:US
Practice Address - Phone:702-369-2628
Practice Address - Fax:702-792-4328
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine