Provider Demographics
NPI:1174839146
Name:RUSSO, DIANE M (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3510
Mailing Address - Country:US
Mailing Address - Phone:617-825-9660
Mailing Address - Fax:617-288-7898
Practice Address - Street 1:637 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3510
Practice Address - Country:US
Practice Address - Phone:617-825-9660
Practice Address - Fax:617-288-7898
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002810152W00000X
MA4926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110101577AMedicaid