Provider Demographics
NPI:1184681892
Name:RUSSO, JONATHAN MATT (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MATT
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:47 OBERY ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360
Mailing Address - Country:US
Mailing Address - Phone:508-747-1560
Mailing Address - Fax:508-747-5155
Practice Address - Street 1:47 OBERY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2229
Practice Address - Country:US
Practice Address - Phone:508-747-1560
Practice Address - Fax:508-747-5155
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2016-08-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA49964207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3020835Medicaid
MA3020835Medicaid
M15221Medicare Oscar/Certification