Provider Demographics
NPI:1225121049
Name:JOIE RUSSO D.O. A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JOIE RUSSO D.O. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-757-2345
Mailing Address - Street 1:18034 VENTURA BLVD #332
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436
Mailing Address - Country:US
Mailing Address - Phone:818-757-0457
Mailing Address - Fax:
Practice Address - Street 1:5525 ETIWANDA AVE #315
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-757-2345
Practice Address - Fax:818-757-0137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8335207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA115297Medicare UPIN
CAW17876Medicare PIN
CA20A8335Medicare ID - Type Unspecified