Provider Demographics
NPI:1235290966
Name:RUSSO, NEIL J (MD)
Entity Type:Individual
Prefix:MR
First Name:NEIL
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:375 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2724
Mailing Address - Country:US
Mailing Address - Phone:973-731-7707
Mailing Address - Fax:973-669-0277
Practice Address - Street 1:375 MOUNT PLEASANT AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2724
Practice Address - Country:US
Practice Address - Phone:973-731-7707
Practice Address - Fax:973-669-0277
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA 56453207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1 K3466OtherPHS
EP241OtherOXFORD
5383958OtherCIGNA
NJ766860NYHMedicaid
2243108OtherAETNA
NJ766860NYHMedicaid
EP241OtherOXFORD